Healthcare Provider Details

I. General information

NPI: 1447586136
Provider Name (Legal Business Name): KRISTINA M IJOMAH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2009
Last Update Date: 10/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2236 MARSHALL AVE
SAINT PAUL MN
55104-5799
US

IV. Provider business mailing address

2236 MARSHALL AVE
SAINT PAUL MN
55104-5799
US

V. Phone/Fax

Practice location:
  • Phone: 651-332-5963
  • Fax: 651-659-0161
Mailing address:
  • Phone: 651-332-5963
  • Fax: 651-659-0161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberR108963-5
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: