Provider Demographics
NPI:1437313533
Name:OPUSUNJU, ELLIS
Entity Type:Individual
Prefix:
First Name:ELLIS
Middle Name:
Last Name:OPUSUNJU
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 1:8929 WHITE OAK DR
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-8028
Mailing Address - Country:US
Mailing Address - Phone:614-920-3668
Mailing Address - Fax:
Practice Address - Street 1:8929 WHITE OAK DR
Practice Address - Street 2:
Practice Address - City:CANAL WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:43110-8028
Practice Address - Country:US
Practice Address - Phone:614-920-3668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-17
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN 317533163WH0200X
OH14747363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WH0200XNursing Service ProvidersRegistered NurseHome Health