Healthcare Provider Details

I. General information

NPI: 1154906980
Provider Name (Legal Business Name): CHIMEZIE JOANNA AGOMOH PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2021
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 TURNPIKE ST STE BOFFICE2
CANTON MA
02021-2853
US

IV. Provider business mailing address

1017 TURNPIKE ST STE BOFFICE2
CANTON MA
02021-2853
US

V. Phone/Fax

Practice location:
  • Phone: 774-202-9533
  • Fax: 949-883-2076
Mailing address:
  • Phone: 774-202-9533
  • Fax: 949-883-2076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN270236
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN270236
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: