Provider Demographics
NPI:1326548637
Name:OMALE, INNOCENT (FNP)
Entity Type:Individual
Prefix:
First Name:INNOCENT
Middle Name:
Last Name:OMALE
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 RIDGE HAVEN DR
Mailing Address - Street 2:412
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76011-9061
Mailing Address - Country:US
Mailing Address - Phone:469-684-2022
Mailing Address - Fax:
Practice Address - Street 1:2900 HIGHWAY 121 STE 120
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-4033
Practice Address - Country:US
Practice Address - Phone:817-921-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP136144363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily