Provider Demographics
NPI:1073536942
Name:OHAEGBULAM, EMMA BERNICE (CNM ARNP)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:BERNICE
Last Name:OHAEGBULAM
Suffix:
Gender:F
Credentials:CNM ARNP
Other - Prefix:
Other - First Name:EMMA
Other - Middle Name:
Other - Last Name:BOLDEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13110 ELK MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-7182
Mailing Address - Country:US
Mailing Address - Phone:813-349-7568
Mailing Address - Fax:813-349-7561
Practice Address - Street 1:508 N MARYLAND AVE
Practice Address - Street 2:PLANT CITY FAMILY CARE
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563
Practice Address - Country:US
Practice Address - Phone:813-349-7600
Practice Address - Fax:813-349-7561
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP673682363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL033159700Medicaid
P56960Medicare UPIN
E7269ZMedicare ID - Type Unspecified