Healthcare Provider Details

I. General information

NPI: 1689336539
Provider Name (Legal Business Name): IMO ENE INYANG RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL CENTER DR
SPRINGFIELD OH
45504-2687
US

IV. Provider business mailing address

3808 FAIRWAY PARK DR APT 205
COPLEY OH
44321-2973
US

V. Phone/Fax

Practice location:
  • Phone: 937-523-1000
  • Fax:
Mailing address:
  • Phone: 781-974-8216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN.461010
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.0020456
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: