Provider Demographics
NPI:1811719511
Name:IDUSUYI, INNOCENT
Entity type:Individual
Prefix:
First Name:INNOCENT
Middle Name:
Last Name:IDUSUYI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2766 KEATS AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-6965
Mailing Address - Country:US
Mailing Address - Phone:559-701-5394
Mailing Address - Fax:
Practice Address - Street 1:2766 KEATS AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6965
Practice Address - Country:US
Practice Address - Phone:559-701-5394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-25
Last Update Date:2024-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95136042163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse