Provider Demographics
NPI:1376326199
Name:IJEOMAH, MIRABEL CHISOM
Entity Type:Individual
Prefix:
First Name:MIRABEL
Middle Name:CHISOM
Last Name:IJEOMAH
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 1:5325 GRANADA HILLS DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-8580
Mailing Address - Country:US
Mailing Address - Phone:919-896-4651
Mailing Address - Fax:
Practice Address - Street 1:5325 GRANADA HILLS DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27613-8580
Practice Address - Country:US
Practice Address - Phone:919-896-4651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program