Provider Demographics
NPI:1982322814
Name:FAGBOYEGUN, OMOLOLA OLAMIDE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:OMOLOLA
Middle Name:OLAMIDE
Last Name:FAGBOYEGUN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BAYSHORE DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-6709
Mailing Address - Country:US
Mailing Address - Phone:817-262-0506
Mailing Address - Fax:
Practice Address - Street 1:800 BAYSHORE DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-6709
Practice Address - Country:US
Practice Address - Phone:817-262-0506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-17
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1089643363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health