Healthcare Provider Details

I. General information

NPI: 1801203104
Provider Name (Legal Business Name): IFEOMA OGBONNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: IFEOMA OKWUOSA

II. Dates (important events)

Enumeration Date: 07/18/2014
Last Update Date: 07/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 MYRON ST SUITE A
WEST SPRINGFIELD MA
01089-1598
US

IV. Provider business mailing address

49 GEORGE H GILLESPIE WAY
ABINGTON MA
02351-2199
US

V. Phone/Fax

Practice location:
  • Phone: 413-592-1980
  • Fax: 413-439-0100
Mailing address:
  • Phone: 413-592-1980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2271996
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: