Healthcare Provider Details

I. General information

NPI: 1295185213
Provider Name (Legal Business Name): NYARADZO OGUNWO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 AZTEK PL
FAYETTEVILLE NC
28314-6112
US

IV. Provider business mailing address

1315 AZTEK PL
FAYETTEVILLE NC
28314-6112
US

V. Phone/Fax

Practice location:
  • Phone: 910-723-5489
  • Fax:
Mailing address:
  • Phone: 910-723-5489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number5008643
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: