Provider Demographics
NPI:1003124660
Name:EROMOSELE, IZEHI AGENMONMEN (NP)
Entity type:Individual
Prefix:MS
First Name:IZEHI
Middle Name:AGENMONMEN
Last Name:EROMOSELE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 VANDALIA AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11239-2810
Mailing Address - Country:US
Mailing Address - Phone:718-642-3213
Mailing Address - Fax:
Practice Address - Street 1:539 VANDALIA AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11239-2810
Practice Address - Country:US
Practice Address - Phone:718-642-3213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY580957163W00000X
NY341154-01363LF0000X
NY341154363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse