Provider Demographics
NPI:1780211342
Name:EJIOGU, CHIOMA BLESSING
Entity Type:Individual
Prefix:
First Name:CHIOMA
Middle Name:BLESSING
Last Name:EJIOGU
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 1:6015 TIMBERTOP LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-7507
Mailing Address - Country:US
Mailing Address - Phone:727-641-9107
Mailing Address - Fax:
Practice Address - Street 1:4707 SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-2117
Practice Address - Country:US
Practice Address - Phone:919-324-0770
Practice Address - Fax:704-413-3669
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2020-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27305363LF0000X
NC5013224363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily