Provider Demographics
NPI:1093050940
Name:FYATT HEALTHCARE
Entity Type:Organization
Organization Name:FYATT HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:OLUWAYEMISI
Authorized Official - Middle Name:
Authorized Official - Last Name:AGBOOLA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:267-872-9756
Mailing Address - Street 1:1608 WINDSONG TRL
Mailing Address - Street 2:615
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76120-4223
Mailing Address - Country:US
Mailing Address - Phone:267-872-9756
Mailing Address - Fax:
Practice Address - Street 1:1608 WINDSONG TRL
Practice Address - Street 2:615
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76120-4223
Practice Address - Country:US
Practice Address - Phone:267-872-9756
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX798898261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service