Provider Demographics
NPI:1104642966
Name:ENOMA, TEMITOPE EDOMWONYI
Entity type:Individual
Prefix:
First Name:TEMITOPE
Middle Name:EDOMWONYI
Last Name:ENOMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TEMITOPE
Other - Middle Name:
Other - Last Name:ENOMA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:7602 SURREY GROVE COURT
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079
Mailing Address - Country:US
Mailing Address - Phone:240-234-6470
Mailing Address - Fax:
Practice Address - Street 1:7602 SURREY GROVE COURT
Practice Address - Street 2:
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079
Practice Address - Country:US
Practice Address - Phone:240-234-6470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002103911164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse