Provider Demographics
NPI:1639756760
Name:JOHNSON, OMOTOLA IYABO (PMHNP BC)
Entity type:Individual
Prefix:
First Name:OMOTOLA
Middle Name:IYABO
Last Name:JOHNSON
Suffix:
Gender:
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 1:2420 FANNIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77002-9114
Mailing Address - Country:US
Mailing Address - Phone:832-831-3651
Mailing Address - Fax:832-831-3652
Practice Address - Street 1:2420 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77002-9114
Practice Address - Country:US
Practice Address - Phone:832-831-3651
Practice Address - Fax:832-831-3652
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-25
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1032755363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health