Provider Demographics
NPI:1447001284
Name:ANEGBODE, LOVELY
Entity type:Individual
Prefix:
First Name:LOVELY
Middle Name:
Last Name:ANEGBODE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14723 T C JESTER BLVD APT 1216
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77068-2167
Mailing Address - Country:US
Mailing Address - Phone:347-421-5432
Mailing Address - Fax:
Practice Address - Street 1:14723 T C JESTER BLVD APT 1216
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77068-2167
Practice Address - Country:US
Practice Address - Phone:347-421-5432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-29
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1157503363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty