Provider Demographics
NPI:1215201074
Name:BOATENG, EMMANUEL KWAKU
Entity Type:Individual
Prefix:MR
First Name:EMMANUEL
Middle Name:KWAKU
Last Name:BOATENG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 SLEEPY HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:OH
Mailing Address - Zip Code:45050-1759
Mailing Address - Country:US
Mailing Address - Phone:513-360-0865
Mailing Address - Fax:
Practice Address - Street 1:945 SLEEPY HOLLOW DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:OH
Practice Address - Zip Code:45050-1759
Practice Address - Country:US
Practice Address - Phone:513-360-0865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-25
Last Update Date:2012-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH146184164W00000X, 164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2998243Medicaid