Provider Demographics
NPI:1609601491
Name:OSEMENE, VIVIAN IJEMABA
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:IJEMABA
Last Name:OSEMENE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4219 N SUMMERCREST LOOP
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-1087
Mailing Address - Country:US
Mailing Address - Phone:512-740-5441
Mailing Address - Fax:
Practice Address - Street 1:2203 W 35TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78703-1203
Practice Address - Country:US
Practice Address - Phone:512-454-4731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX888034363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health