Provider Demographics
NPI:1164922381
Name:OGBEBOR, ROMELLA M
Entity Type:Individual
Prefix:
First Name:ROMELLA
Middle Name:M
Last Name:OGBEBOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19437 N NEW TRADITION RD
Mailing Address - Street 2:
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85376-5981
Mailing Address - Country:US
Mailing Address - Phone:800-674-3510
Mailing Address - Fax:800-674-3510
Practice Address - Street 1:29751 N 121ST DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-3498
Practice Address - Country:US
Practice Address - Phone:480-600-1770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ05Medicaid