MEDICARE: STELLA O EJIOGU

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner	11027346	FL

General Provider Information

NPI Number	:	1821778598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STELLA O EJIOGU

Provider Business Mailing Address
First Line	:	2249 LAKE HERITAGE DR
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32311-9486
Country	:	US
Telephone Number	:	850-345-7607
Fax Number	:

Provider Business Practice Location Address
First Line	:	2249 LAKE HERITAGE DR
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32311-9486
Country	:	US
Telephone Number	:	850-345-7607
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2023
Last Update Date	:	07/19/2023

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