Provider Demographics
NPI:1649626847
Name:OBIORA, IFEOMA ALEXANDRIA (APRN)
Entity type:Individual
Prefix:
First Name:IFEOMA
Middle Name:ALEXANDRIA
Last Name:OBIORA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-2325
Mailing Address - Country:US
Mailing Address - Phone:617-778-4390
Mailing Address - Fax:
Practice Address - Street 1:219 RIVER RD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-2325
Practice Address - Country:US
Practice Address - Phone:617-778-4390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-06
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2302865163W00000X, 363L00000X, 363LP2300X, 363LP0808X
RICAPRN01958363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MARN2302865Medicaid
RICAPRN01958Medicaid