Provider Demographics
NPI:1215213483
Name:IDUSOGIE, IZETTA BARWU (RN)
Entity Type:Individual
Prefix:
First Name:IZETTA
Middle Name:BARWU
Last Name:IDUSOGIE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2236 MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-5799
Mailing Address - Country:US
Mailing Address - Phone:651-659-0208
Mailing Address - Fax:651-659-0161
Practice Address - Street 1:2236 MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-5799
Practice Address - Country:US
Practice Address - Phone:651-659-0208
Practice Address - Fax:651-659-0161
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR145398-6163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN868K1CAOtherBCBS