Provider Demographics
NPI:1912750027
Name:UGIAGBE, GLORY OMOSEDE (PMHNP)
Entity Type:Individual
Prefix:
First Name:GLORY
Middle Name:OMOSEDE
Last Name:UGIAGBE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 LANCASTER DR NE STE 110
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1065
Mailing Address - Country:US
Mailing Address - Phone:503-395-8614
Mailing Address - Fax:
Practice Address - Street 1:1880 LANCASTER DR NE STE 110
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1065
Practice Address - Country:US
Practice Address - Phone:503-395-8614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10025785363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health