Provider Demographics
NPI:1679251557
Name:CHIBUOKE, THERESA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:CHIBUOKE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 KIRKWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-1529
Mailing Address - Country:US
Mailing Address - Phone:817-251-4906
Mailing Address - Fax:
Practice Address - Street 1:2131 KIRKWOOD BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-1540
Practice Address - Country:US
Practice Address - Phone:817-251-4906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1115822363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health