Provider Demographics
NPI:1255102976
Name:EBIETOMIYE, KEMISOLA LYNDA
Entity type:Individual
Prefix:
First Name:KEMISOLA
Middle Name:LYNDA
Last Name:EBIETOMIYE
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 1:548 WESTWOOD WAY DR
Mailing Address - Street 2:
Mailing Address - City:HASLET
Mailing Address - State:TX
Mailing Address - Zip Code:76052-3079
Mailing Address - Country:US
Mailing Address - Phone:469-250-1544
Mailing Address - Fax:469-242-9827
Practice Address - Street 1:801 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2733
Practice Address - Country:US
Practice Address - Phone:773-621-8983
Practice Address - Fax:469-242-9827
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-11
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1149539363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health