Provider Demographics
NPI:1710587845
Name:AGOLUE, IJEOMA (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:IJEOMA
Middle Name:
Last Name:AGOLUE
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 1:4645 SAMUELL BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75228-6826
Mailing Address - Country:US
Mailing Address - Phone:214-275-7393
Mailing Address - Fax:
Practice Address - Street 1:4645 SAMUELL BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-6826
Practice Address - Country:US
Practice Address - Phone:214-275-7393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1012201363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health