Provider Demographics
NPI:1215307715
Name:OMENUKOR, KEYNA
Entity type:Individual
Prefix:
First Name:KEYNA
Middle Name:
Last Name:OMENUKOR
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 1:1675 REPUBLIC PKWY STE 190
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-6902
Mailing Address - Country:US
Mailing Address - Phone:972-576-7399
Mailing Address - Fax:972-476-0006
Practice Address - Street 1:1675 REPUBLIC PKWY STE 190
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6902
Practice Address - Country:US
Practice Address - Phone:972-576-7399
Practice Address - Fax:972-476-0006
Is Sole Proprietor?:No
Enumeration Date:2015-09-28
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024286045363LP0808X
WAAP61500520363LP0808X
TXAP128934363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health