Healthcare Provider Details

I. General information

NPI: 1821494840
Provider Name (Legal Business Name): IJEOMA EDITH MGBARAHO AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2014
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 FANNIN ST
HOUSTON TX
77030-2703
US

IV. Provider business mailing address

6565 FANNIN ST
HOUSTON TX
77030-2703
US

V. Phone/Fax

Practice location:
  • Phone: 832-208-2973
  • Fax:
Mailing address:
  • Phone: 832-208-2973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP126949
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: