Provider Demographics
NPI:1558768507
Name:OSAIGBOVO, REBECCA (RN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:OSAIGBOVO
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 1:522 S MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-3837
Mailing Address - Country:US
Mailing Address - Phone:734-585-7970
Mailing Address - Fax:
Practice Address - Street 1:522 S MAPLE RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-3837
Practice Address - Country:US
Practice Address - Phone:734-585-7970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-19
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704171726163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI$$$$$$$$$Medicaid