Provider Demographics
NPI:1255115473
Name:EKOBENA, IRENE ENJEMA (NP)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:ENJEMA
Last Name:EKOBENA
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 2ND ST STE 204
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-2015
Mailing Address - Country:US
Mailing Address - Phone:612-787-8408
Mailing Address - Fax:612-567-8935
Practice Address - Street 1:464 2ND ST STE 204
Practice Address - Street 2:
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-2015
Practice Address - Country:US
Practice Address - Phone:612-787-8408
Practice Address - Fax:612-567-8935
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10642363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology