Provider Demographics
NPI:1417457185
Name:OBONNA, FESTUS C
Entity Type:Individual
Prefix:MR
First Name:FESTUS
Middle Name:C
Last Name:OBONNA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 SHADY GROVE CT
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-8144
Mailing Address - Country:US
Mailing Address - Phone:865-696-9226
Mailing Address - Fax:
Practice Address - Street 1:9300 JOHN HICKMAN PKWY STE 904
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035-5894
Practice Address - Country:US
Practice Address - Phone:865-696-9226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX817267163W00000X
TXAP143752363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse