Basic Information
Provider Information | |||||||||
NPI: | 1073807632 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WOLUGBOMS | ||||||||
FirstName: | NELLY | ||||||||
MiddleName: | O | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ITSUOKO | ||||||||
OtherFirstName: | NELLY | ||||||||
OtherMiddleName: | OGHOSOMI | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2711 FOSTER AVE | ||||||||
Address2: |   | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372105307 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6156208647 | ||||||||
FaxNumber: | 6155155773 | ||||||||
Practice Location | |||||||||
Address1: | 100 DAMASCUS ST | ||||||||
Address2: |   | ||||||||
City: | HARTSVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 370741502 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6152273000 | ||||||||
FaxNumber: | 6155155773 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2011 | ||||||||
LastUpdateDate: | 07/09/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN0000015556 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.