Provider Demographics
NPI:1417468604
Name:EJIOGU, CAROLINE C
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:C
Last Name:EJIOGU
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 1:10811 171ST PL
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11433-3027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23214 MERRICK BLVD
Practice Address - Street 2:
Practice Address - City:LAURELTON
Practice Address - State:NY
Practice Address - Zip Code:11413-2115
Practice Address - Country:US
Practice Address - Phone:718-528-3432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY314036164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNX11550BMedicaid