Provider Demographics
NPI:1679136220
Name:ODUAGU, MARVISE IJEOMA
Entity Type:Individual
Prefix:
First Name:MARVISE
Middle Name:IJEOMA
Last Name:ODUAGU
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 1:305 W COMMERCE ST APT 336
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-1985
Mailing Address - Country:US
Mailing Address - Phone:214-597-4465
Mailing Address - Fax:
Practice Address - Street 1:305 W COMMERCE ST APT 336
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-1985
Practice Address - Country:US
Practice Address - Phone:214-597-4465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30020363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX30020OtherTEXAS BOARD OF NURSING