Provider Demographics
NPI:1982217873
Name:IHEROBIEM, IFEOMA E
Entity Type:Individual
Prefix:
First Name:IFEOMA
Middle Name:E
Last Name:IHEROBIEM
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 1:884 S SPRINGFIELD AVE APT 18
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-3320
Mailing Address - Country:US
Mailing Address - Phone:862-371-8667
Mailing Address - Fax:
Practice Address - Street 1:884 S SPRINGFIELD AVE APT 18
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-3320
Practice Address - Country:US
Practice Address - Phone:862-371-8667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01049500363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty