Provider Demographics
NPI:1689261513
Name:ODU-ONIKOSI, MODUPEOLUWA MARIAM
Entity Type:Individual
Prefix:
First Name:MODUPEOLUWA
Middle Name:MARIAM
Last Name:ODU-ONIKOSI
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 1:4170 SHAVANO DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-9649
Mailing Address - Country:US
Mailing Address - Phone:214-960-6652
Mailing Address - Fax:
Practice Address - Street 1:4170 SHAVANO DR
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-9649
Practice Address - Country:US
Practice Address - Phone:214-960-6652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-27
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX880756163WP0808X
TX1026808364SP0810X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0810XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Family
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health