Basic Information
Provider Information | |||||||||
NPI: | 1285296384 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | IWEBO | ||||||||
FirstName: | JANE | ||||||||
MiddleName: | NGOZI | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PMHNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NWABUFO | ||||||||
OtherFirstName: | JANE | ||||||||
OtherMiddleName: | NGOZI | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1978 | ||||||||
Address2: |   | ||||||||
City: | SALISBURY | ||||||||
State: | MD | ||||||||
PostalCode: | 218021978 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4107491015 | ||||||||
FaxNumber: | 4107490654 | ||||||||
Practice Location | |||||||||
Address1: | 560 RIVERSIDE DR STE A204 | ||||||||
Address2: |   | ||||||||
City: | SALISBURY | ||||||||
State: | MD | ||||||||
PostalCode: | 218014704 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4433586193 | ||||||||
FaxNumber: | 4433586197 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/28/2019 | ||||||||
LastUpdateDate: | 09/05/2019 | ||||||||
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 | 363LP0808X | R128087 | MD | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.