MEDICARE: MRS. JOSEHINE IMEDIEGWU EZIOLISA

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	164W00000X	Licensed Practical Nurse	125708	OH

General Provider Information

NPI Number	:	1851580666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JOSEHINE IMEDIEGWU EZIOLISA

Provider Business Mailing Address
First Line	:	7967 MOUNT HOOD
Second Line	:
City	:	HUBER HEIGHTS
State	:	OH
Zip	:	45424-6931
Country	:	US
Telephone Number	:	937-241-2924
Fax Number	:

Provider Business Practice Location Address
First Line	:	7967 MOUNT HOOD
Second Line	:
City	:	HUBER HEIGHTS
State	:	OH
Zip	:	45424-6931
Country	:	US
Telephone Number	:	937-241-2924
Fax Number	:

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

Provider Enumeration Date	:	10/17/2007
Last Update Date	:	10/17/2007

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