Healthcare Provider Details

I. General information

NPI: 1356960322
Provider Name (Legal Business Name): FIDELIA OKWEREOGU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 04/10/2020
Certification Date: 04/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2521 N ELMS RD
FLUSHING MI
48433-9423
US

IV. Provider business mailing address

2521 N ELMS RD
FLUSHING MI
48433-9423
US

V. Phone/Fax

Practice location:
  • Phone: 810-487-5571
  • Fax:
Mailing address:
  • Phone: 810-487-5571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704173551
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: