Provider Demographics
NPI:1558482596
Name:EZENWA, MIRIAM OMELEBELE (RN)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:OMELEBELE
Last Name:EZENWA
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 1:608 EAGLE HTS APT C
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-1529
Mailing Address - Country:US
Mailing Address - Phone:608-238-6205
Mailing Address - Fax:608-238-6205
Practice Address - Street 1:608 EAGLE HTS APT C
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-1529
Practice Address - Country:US
Practice Address - Phone:608-238-6205
Practice Address - Fax:608-238-6205
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35008100Medicaid