Provider Demographics
NPI:1578029591
Name:BAZUAYE, EGHEOSA
Entity Type:Individual
Prefix:
First Name:EGHEOSA
Middle Name:
Last Name:BAZUAYE
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 1:1625 CONLEY RD APT 149
Mailing Address - Street 2:
Mailing Address - City:CONLEY
Mailing Address - State:GA
Mailing Address - Zip Code:30288-1869
Mailing Address - Country:US
Mailing Address - Phone:770-789-3833
Mailing Address - Fax:
Practice Address - Street 1:1625 CONLEY RD APT 149
Practice Address - Street 2:
Practice Address - City:CONLEY
Practice Address - State:GA
Practice Address - Zip Code:30288-1869
Practice Address - Country:US
Practice Address - Phone:770-789-3833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health