Provider Demographics
NPI:1033703939
Name:OMOROGHOMWAN, ABIEYUWA (LPN)
Entity Type:Individual
Prefix:
First Name:ABIEYUWA
Middle Name:
Last Name:OMOROGHOMWAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-3810
Mailing Address - Country:US
Mailing Address - Phone:857-251-2391
Mailing Address - Fax:
Practice Address - Street 1:7 PARKER ST
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-3810
Practice Address - Country:US
Practice Address - Phone:857-251-2391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-22
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN86532164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse