Provider Demographics
NPI:1174008999
Name:ITOE, JUSTIN NGULAH
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:NGULAH
Last Name:ITOE
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 1:3501 N BUCKNER BLVD APT 1016
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75228-5691
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3501 N BUCKNER BLVD APT 1016
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-5691
Practice Address - Country:US
Practice Address - Phone:323-424-0994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX953831163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse