Provider Demographics
NPI:1801607346
Name:SEFOGBE, IRENE
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:SEFOGBE
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 1:31 BUSINESS TER
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02136-2159
Mailing Address - Country:US
Mailing Address - Phone:617-429-3267
Mailing Address - Fax:
Practice Address - Street 1:31 BUSINESS TER
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02136-2159
Practice Address - Country:US
Practice Address - Phone:617-429-3267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2372712364SM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical