Provider Demographics
NPI:1154851129
Name:IHEANACHO, OLIVIA CHINONSO
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:CHINONSO
Last Name:IHEANACHO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 COLLIER ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-2911
Mailing Address - Country:US
Mailing Address - Phone:512-472-4357
Mailing Address - Fax:512-703-1394
Practice Address - Street 1:4131 SPICEWOOD SPRINGS RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8661
Practice Address - Country:US
Practice Address - Phone:512-732-2122
Practice Address - Fax:512-732-2124
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX835635163W00000X
TX1105564363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse