Provider Demographics
NPI:1356996326
Name:ENEBONG, EDIOMI EDET (NP)
Entity type:Individual
Prefix:
First Name:EDIOMI
Middle Name:EDET
Last Name:ENEBONG
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 1:4925 S BROADWAY AVE # 1077
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67216-3716
Mailing Address - Country:US
Mailing Address - Phone:507-353-2419
Mailing Address - Fax:507-607-8967
Practice Address - Street 1:4925 S BROADWAY AVE # 1077
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67216-3716
Practice Address - Country:US
Practice Address - Phone:507-353-2419
Practice Address - Fax:507-607-8967
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142164363LP0808X
KS82079363LP0808X
MN8117363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health