Basic Information
| Provider Information | |||||||||
| NPI: | 1255952016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ONWUMERE | ||||||||
| FirstName: | NNENNA | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 253 COVINGTON WAY | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2348060542 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 GARFIELD AVE | ||||||||
| Address2: | RM G102 | ||||||||
| City: | PAKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044244575 | ||||||||
| FaxNumber: | 3044244577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2020 | ||||||||
| LastUpdateDate: | 03/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/11/2022 | ||||||||
| NPIReactivationDate: | 03/01/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.