Provider Demographics
NPI:1245644798
Name:OFOBUZO, MIRIAM
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:OFOBUZO
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 1:105 RIDGEWOOD AVE APT C
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07108-2423
Mailing Address - Country:US
Mailing Address - Phone:908-344-0994
Mailing Address - Fax:
Practice Address - Street 1:34 BEACH ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-2702
Practice Address - Country:US
Practice Address - Phone:718-815-8089
Practice Address - Fax:718-815-8062
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY312830-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse