Healthcare Provider Details

I. General information

NPI: 1083973184
Provider Name (Legal Business Name): CHISOM OGBONNAYA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2012
Last Update Date: 05/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 TREBLE DR STE 18
HUMBLE TX
77338-5284
US

IV. Provider business mailing address

9894 BISSONNET ST STE 916
HOUSTON TX
77036-8272
US

V. Phone/Fax

Practice location:
  • Phone: 832-425-5668
  • Fax:
Mailing address:
  • Phone: 713-271-6900
  • Fax: 713-271-6901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number1000815
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: