Provider Demographics
NPI:1811475841
Name:ENYIDEDE, IHUOMA CHINAGOROM
Entity type:Individual
Prefix:MRS
First Name:IHUOMA
Middle Name:CHINAGOROM
Last Name:ENYIDEDE
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 1:2218 LAUREL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77014
Mailing Address - Country:US
Mailing Address - Phone:832-576-3556
Mailing Address - Fax:
Practice Address - Street 1:602 W SEMANDS STREET
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301
Practice Address - Country:US
Practice Address - Phone:936-756-5598
Practice Address - Fax:936-249-2244
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX231123164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse