Healthcare Provider Details

I. General information

NPI: 1558482596
Provider Name (Legal Business Name): MIRIAM OMELEBELE EZENWA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 EAGLE HTS APT C
MADISON WI
53705-1529
US

IV. Provider business mailing address

608 EAGLE HTS APT C
MADISON WI
53705-1529
US

V. Phone/Fax

Practice location:
  • Phone: 608-238-6205
  • Fax: 608-238-6205
Mailing address:
  • Phone: 608-238-6205
  • Fax: 608-238-6205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: