Provider Demographics
NPI:1669882601
Name:EDIYE ENOOBONG
Entity type:Organization
Organization Name:EDIYE ENOOBONG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PRACTICAL NURSE
Authorized Official - Prefix:
Authorized Official - First Name:EDIYE
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:ENOOBONG
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE
Authorized Official - Phone:614-377-9044
Mailing Address - Street 1:4672 HARBINGER CIR W
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:OH
Mailing Address - Zip Code:43213-6115
Mailing Address - Country:US
Mailing Address - Phone:614-377-9044
Mailing Address - Fax:614-453-5712
Practice Address - Street 1:4672 HARBINGER CIR W
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:OH
Practice Address - Zip Code:43213-6115
Practice Address - Country:US
Practice Address - Phone:614-377-9044
Practice Address - Fax:614-453-5712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-29
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH156004311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home