Healthcare Provider Details

I. General information

NPI: 1336385095
Provider Name (Legal Business Name): EDITH OLUCHI OGBENNA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2008
Last Update Date: 12/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 VERNON BLVD
LONG ISLAND CITY NY
11106-5121
US

IV. Provider business mailing address

22548 111TH AVE
QUEENS VILLAGE NY
11429-2803
US

V. Phone/Fax

Practice location:
  • Phone: 718-726-8484
  • Fax:
Mailing address:
  • Phone: 646-270-8383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF335417-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: