Provider Demographics
NPI:1396456174
Name:OMODUGBA-UDEH, CHRISTIANA UPE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:CHRISTIANA
Middle Name:UPE
Last Name:OMODUGBA-UDEH
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 MONTE CARLO DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-6221
Mailing Address - Country:US
Mailing Address - Phone:469-226-3119
Mailing Address - Fax:
Practice Address - Street 1:1508 MONTE CARLO DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-6221
Practice Address - Country:US
Practice Address - Phone:469-226-3119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-12
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2022026825363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health