Provider Demographics
NPI:1639756760
Name:JOHNSON, OMOTOLA IYABO (PMHNP BC)
Entity Type:Individual
Prefix:
First Name:OMOTOLA
Middle Name:IYABO
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PMHNP BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7607 GRAPE ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77074-4223
Mailing Address - Country:US
Mailing Address - Phone:401-499-0776
Mailing Address - Fax:
Practice Address - Street 1:7607 GRAPE ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-4223
Practice Address - Country:US
Practice Address - Phone:401-499-0776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1032755364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health