Provider Demographics
NPI:1679061139
Name:OKUNDAYE, EDITH OSAMUEDE
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:OSAMUEDE
Last Name:OKUNDAYE
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 1:803 DOVER HEIGHTS TRL
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-2895
Mailing Address - Country:US
Mailing Address - Phone:817-404-6881
Mailing Address - Fax:
Practice Address - Street 1:803 DOVER HEIGHTS TRL
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-2895
Practice Address - Country:US
Practice Address - Phone:817-404-6881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX180996164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse