Provider Demographics
NPI:1841701323
Name:OMAKOR, ELO EDITH (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:ELO
Middle Name:EDITH
Last Name:OMAKOR
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1805
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-0017
Mailing Address - Country:US
Mailing Address - Phone:682-272-5143
Mailing Address - Fax:972-440-2057
Practice Address - Street 1:215 DALTON DR
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-4454
Practice Address - Country:US
Practice Address - Phone:682-272-5143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP135575363LP0808X
NV847722363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health