Provider Demographics
NPI:1154542652
Name:ODIMEGWU, ROSE NGOZI (NP)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:NGOZI
Last Name:ODIMEGWU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 BROOKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02346-3148
Mailing Address - Country:US
Mailing Address - Phone:781-510-9793
Mailing Address - Fax:
Practice Address - Street 1:1200 BRUSH HILL RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-2337
Practice Address - Country:US
Practice Address - Phone:617-913-3340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA211849163W00000X
MARN211849363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110093957AMedicaid
MA110093957AMedicaid