Provider Demographics
NPI:1538676614
Name:NDUBISI, IFEOMA BENEDETH
Entity Type:Individual
Prefix:
First Name:IFEOMA
Middle Name:BENEDETH
Last Name:NDUBISI
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 1:428 CORONADO AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90814-1588
Mailing Address - Country:US
Mailing Address - Phone:562-506-7185
Mailing Address - Fax:
Practice Address - Street 1:1775 CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-1674
Practice Address - Country:US
Practice Address - Phone:562-599-8444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN683255164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse