Provider Demographics
NPI:1396564548
Name:NWOBU, IJEOMA MIRACLE
Entity type:Individual
Prefix:
First Name:IJEOMA
Middle Name:MIRACLE
Last Name:NWOBU
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 1:53 PHILIP PL
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-2908
Mailing Address - Country:US
Mailing Address - Phone:917-224-8622
Mailing Address - Fax:
Practice Address - Street 1:301 SICOMAC AVE
Practice Address - Street 2:
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481-2159
Practice Address - Country:US
Practice Address - Phone:917-224-8622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-05
Last Update Date:2024-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ06356750363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health