Provider Demographics
NPI:1043769284
Name:OBIDIAKU, MARYROSE (NP)
Entity Type:Individual
Prefix:
First Name:MARYROSE
Middle Name:
Last Name:OBIDIAKU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 E CORPORATE DR APT 335
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-6682
Mailing Address - Country:US
Mailing Address - Phone:214-789-7987
Mailing Address - Fax:
Practice Address - Street 1:5500 N MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2603
Practice Address - Country:US
Practice Address - Phone:972-518-1325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-29
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP131624363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily