Provider Demographics
NPI:1780277269
Name:OWALLA, DORINE OWEKE
Entity type:Individual
Prefix:
First Name:DORINE
Middle Name:OWEKE
Last Name:OWALLA
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 1:9812 AMARANTH DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76177-3217
Mailing Address - Country:US
Mailing Address - Phone:817-449-3005
Mailing Address - Fax:
Practice Address - Street 1:9812 AMARANTH DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-3217
Practice Address - Country:US
Practice Address - Phone:817-449-3005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX780817363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health