Provider Demographics
NPI:1649529900
Name:IBEZIM, GLORIA OZIOMA (FAMILY NURSE PRACT)
Entity type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:OZIOMA
Last Name:IBEZIM
Suffix:
Gender:F
Credentials:FAMILY NURSE PRACT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 AMBERLY CIR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-2602
Mailing Address - Country:US
Mailing Address - Phone:585-354-9628
Mailing Address - Fax:
Practice Address - Street 1:620 WESTFALL RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-4610
Practice Address - Country:US
Practice Address - Phone:585-461-8580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY574544163W00000X
NYF08170262363L00000X, 363LF0000X
NYFO8170262364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1649529900Medicaid