Provider Demographics
NPI:1033867007
Name:SOFELA, OMOTAYO Y (NP)
Entity type:Individual
Prefix:MRS
First Name:OMOTAYO
Middle Name:Y
Last Name:SOFELA
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 1:12000 RICHMOND AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77082-2429
Mailing Address - Country:US
Mailing Address - Phone:832-361-8577
Mailing Address - Fax:
Practice Address - Street 1:12000 RICHMOND AVE STE 130
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77082-2429
Practice Address - Country:US
Practice Address - Phone:832-361-8577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1069874363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health