Healthcare Provider Details

I. General information

NPI: 1083578769
Provider Name (Legal Business Name): IJEOMA AGNES MBIONWU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 W COLONIAL DR STE 100
ORLANDO FL
32808-7602
US

IV. Provider business mailing address

5000 W COLONIAL DR STE 100
ORLANDO FL
32808-7602
US

V. Phone/Fax

Practice location:
  • Phone: 407-291-1236
  • Fax:
Mailing address:
  • Phone: 407-291-1236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2025084602
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: