Provider Demographics
NPI:1659746675
Name:STEDICLINIC PLLC
Entity Type:Organization
Organization Name:STEDICLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:OLAYINKA
Authorized Official - Middle Name:
Authorized Official - Last Name:AGBODO
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:832-745-8742
Mailing Address - Street 1:4560 FM 1960 RD W STE 106
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77069-4628
Mailing Address - Country:US
Mailing Address - Phone:832-286-1061
Mailing Address - Fax:832-286-1267
Practice Address - Street 1:4560 FM 1960 RD W STE 106
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77069
Practice Address - Country:US
Practice Address - Phone:832-286-1061
Practice Address - Fax:832-286-1267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-02
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261Q00000X
TXAP128483363LF0000X
TXAP130092363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX358389004Medicaid
TX3604894Medicaid
TX1659746675Medicaid