Provider Demographics
NPI:1306325790
Name:ODUNAYO, CORDELIA (NP)
Entity type:Individual
Prefix:
First Name:CORDELIA
Middle Name:
Last Name:ODUNAYO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 WEYBURN DR
Mailing Address - Street 2:
Mailing Address - City:VENUS
Mailing Address - State:TX
Mailing Address - Zip Code:76084-1190
Mailing Address - Country:US
Mailing Address - Phone:817-703-6011
Mailing Address - Fax:
Practice Address - Street 1:110 W RANDOL MILL RD STE 200
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-4612
Practice Address - Country:US
Practice Address - Phone:214-892-7151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138725363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP138725Medicaid