Healthcare Provider Details

I. General information

NPI: 1982306429
Provider Name (Legal Business Name): ETIOSA OSARIEMEN OSEMWINYEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 07/09/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 DATES DR
ITHACA NY
14850-1383
US

IV. Provider business mailing address

101 DATES DR
ITHACA NY
14850-1383
US

V. Phone/Fax

Practice location:
  • Phone: 607-274-4225
  • Fax:
Mailing address:
  • Phone: 607-339-0494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: