Provider Demographics
NPI:1184139362
Name:OMOTAYO, STEPHANIE (DNP)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:OMOTAYO
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 W HIGHWAY 287 BUSINESS STE 104
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-4728
Mailing Address - Country:US
Mailing Address - Phone:469-414-2615
Mailing Address - Fax:469-242-9743
Practice Address - Street 1:1014 FERRIS AVE STE 108B
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-2599
Practice Address - Country:US
Practice Address - Phone:469-414-2615
Practice Address - Fax:469-242-9743
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-09
Last Update Date:2025-06-06
Deactivation Date:2017-12-19
Deactivation Code:
Reactivation Date:2018-02-07
Provider Licenses
StateLicense IDTaxonomies
TXAP135407363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily