Healthcare Provider Details

I. General information

NPI: 1538093067
Provider Name (Legal Business Name): ELOM KOSSIVI GREGORY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7714 N 113TH AVENUE CIR
OMAHA NE
68142-1140
US

IV. Provider business mailing address

7714 N 113TH AVENUE CIR
OMAHA NE
68142-1140
US

V. Phone/Fax

Practice location:
  • Phone: 402-238-4034
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number77445
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: