Healthcare Provider Details

I. General information

NPI: 1710355839
Provider Name (Legal Business Name): VIVIEN ANWULI IJOMAH REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2015
Last Update Date: 09/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1590 MAHOGANY DR
ALLEN TX
75002-0946
US

IV. Provider business mailing address

1590 MAHOGANY DR
ALLEN TX
75002-0946
US

V. Phone/Fax

Practice location:
  • Phone: 469-879-2707
  • Fax:
Mailing address:
  • Phone: 469-879-2707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number731760
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number731760
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: