Provider Demographics
NPI:1013735109
Name:ITSOSIME EKHATOR, TRACY EBOSHOGUE
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:EBOSHOGUE
Last Name:ITSOSIME EKHATOR
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 1:1543 159TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-4563
Mailing Address - Country:US
Mailing Address - Phone:763-913-2216
Mailing Address - Fax:
Practice Address - Street 1:5701 SHINGLE CREEK PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55430-2467
Practice Address - Country:US
Practice Address - Phone:763-453-8752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-28
Last Update Date:2024-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2521094163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse