Provider Demographics
NPI:1275142002
Name:EBHOMIELEN, OMONYEMEN IRENOSEN
Entity Type:Individual
Prefix:
First Name:OMONYEMEN
Middle Name:IRENOSEN
Last Name:EBHOMIELEN
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 1:25630 CRAFT AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-2700
Mailing Address - Country:US
Mailing Address - Phone:718-341-3383
Mailing Address - Fax:
Practice Address - Street 1:560 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3917
Practice Address - Country:US
Practice Address - Phone:212-305-4318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY635881163WC0200X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine