Provider Demographics
NPI:1871762344
Name:OMOHUNDRO, THERESA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:
Last Name:OMOHUNDRO
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 1:5005 N PIEDRAS ST
Mailing Address - Street 2:WILLIAM BEAUMONT ARMY MEDICAL CENTER
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79920-5001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5005 N PIEDRAS ST
Practice Address - Street 2:WILLIAM BEAUMONT ARMY MEDICAL CENTER
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79920-5001
Practice Address - Country:US
Practice Address - Phone:915-569-2723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-28
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP125358363LF0000X
TX727901363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily