Healthcare Provider Details

I. General information

NPI: 1285191254
Provider Name (Legal Business Name): OGECHI NITA ENYIOKO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2019
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30500 VAN DYKE AVE
WARREN MI
48093-2195
US

IV. Provider business mailing address

29714 SOMERSET DR
SOUTHFIELD MI
48076-1871
US

V. Phone/Fax

Practice location:
  • Phone: 248-325-7093
  • Fax:
Mailing address:
  • Phone: 248-325-7093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704289385
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: