Provider Demographics
NPI:1083200208
Name:UDOSEN, ETIDO J (PMHNP-BC, CNP, MSN)
Entity Type:Individual
Prefix:
First Name:ETIDO
Middle Name:J
Last Name:UDOSEN
Suffix:
Gender:M
Credentials:PMHNP-BC, CNP, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6160 WARREN PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-9415
Mailing Address - Country:US
Mailing Address - Phone:972-565-3977
Mailing Address - Fax:
Practice Address - Street 1:6160 WARREN PKWY STE 100
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-9415
Practice Address - Country:US
Practice Address - Phone:197-256-5397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-13
Last Update Date:2023-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1021337363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty