Provider Demographics
NPI:1568758829
Name:EGBEDEJU, ANTHONIA O (FNP)
Entity type:Individual
Prefix:
First Name:ANTHONIA
Middle Name:O
Last Name:EGBEDEJU
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746079
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6079
Mailing Address - Country:US
Mailing Address - Phone:773-352-1513
Mailing Address - Fax:312-929-0373
Practice Address - Street 1:11600 FM 1960 RD W STE A
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065-3516
Practice Address - Country:US
Practice Address - Phone:281-720-8639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-24
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN149732163W00000X
TNAPN154784363LF0000X
MO2019006675363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS53-78721-121OtherSTATE LICENSE
MO2019006675OtherSTATE LICENSE
TNAPN15784OtherSTATE LICENSE
MOME5679420OtherDEA
TNAPN15784OtherSTATE LICENSE