Provider Demographics
NPI:1881484590
Name:OSEMWENKHAE, TRACEY I
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:I
Last Name:OSEMWENKHAE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6302 BROADWAY ST STE 130
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581-7859
Mailing Address - Country:US
Mailing Address - Phone:832-438-0330
Mailing Address - Fax:
Practice Address - Street 1:6302 BROADWAY ST STE 130
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-7859
Practice Address - Country:US
Practice Address - Phone:832-438-0330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1168573363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health