Basic Information
| Provider Information | |||||||||
| NPI: | 1316517709 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UMEH | ||||||||
| FirstName: | OGENNA | ||||||||
| MiddleName: | AGATHA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OFFODILE | ||||||||
| OtherFirstName: | OGENNA | ||||||||
| OtherMiddleName: | AGATHA | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10 S 9TH ST STE 4 | ||||||||
| Address2: | |||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460602631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172043736 | ||||||||
| FaxNumber: | 3177086496 | ||||||||
| Practice Location | |||||||||
| Address1: | 3630 HICKORY RD | ||||||||
| Address2: | |||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465458865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742527225 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2021 | ||||||||
| LastUpdateDate: | 06/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05014167A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.