Healthcare Provider Details

I. General information

NPI: 1649529900
Provider Name (Legal Business Name): GLORIA OZIOMA IBEZIM FAMILY NURSE PRACT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2012
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 WESTFALL RD
ROCHESTER NY
14620-4610
US

IV. Provider business mailing address

3 AMBERLY CIR
ROCHESTER NY
14624-2602
US

V. Phone/Fax

Practice location:
  • Phone: 585-461-8580
  • Fax:
Mailing address:
  • Phone: 585-354-9628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number574544
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF08170262
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberFO8170262
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF08170262
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: