Provider Demographics
NPI:1396032173
Name:OMEREONYE, GOLD A (RN)
Entity Type:Individual
Prefix:
First Name:GOLD
Middle Name:A
Last Name:OMEREONYE
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 1:4238 W HAWTHORNE TRACE RD APT 104
Mailing Address - Street 2:#104
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53209-1026
Mailing Address - Country:US
Mailing Address - Phone:414-975-0121
Mailing Address - Fax:
Practice Address - Street 1:4238 W HAWTHORNE TRACE RD APT 104
Practice Address - Street 2:#104
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53209-1026
Practice Address - Country:US
Practice Address - Phone:414-975-0121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-30
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI126208-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse