Provider Demographics
NPI:1477858397
Name:MBAM, ROSEMARY IJEOMA (APN)
Entity Type:Individual
Prefix:
First Name:ROSEMARY
Middle Name:IJEOMA
Last Name:MBAM
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 EVERGREEN FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:AVENEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07001-2053
Mailing Address - Country:US
Mailing Address - Phone:347-316-7396
Mailing Address - Fax:
Practice Address - Street 1:30218 CASCADING BROOK WAY
Practice Address - Street 2:
Practice Address - City:BROOKSHIRE
Practice Address - State:TX
Practice Address - Zip Code:77423-2786
Practice Address - Country:US
Practice Address - Phone:347-316-7396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-25
Last Update Date:2023-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR19324900163WH1000X
NJ26NJ01025000363L00000X
TX1000194363LP0808X, 364SG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No163WH1000XNursing Service ProvidersRegistered NurseHospiceGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontologyGroup - Multi-Specialty