Provider Demographics
NPI:1205461977
Name:EJINDU, THERESA OLUOMA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:OLUOMA
Last Name:EJINDU
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 1:3000 WALBROOK TER
Mailing Address - Street 2:
Mailing Address - City:BROWNS SUMMIT
Mailing Address - State:NC
Mailing Address - Zip Code:27214-9095
Mailing Address - Country:US
Mailing Address - Phone:336-210-8129
Mailing Address - Fax:
Practice Address - Street 1:3803 N ELM ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-2593
Practice Address - Country:US
Practice Address - Phone:336-296-1599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5012789363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health