Provider Demographics
NPI:1215674791
Name:ODIASE, IZEGBUWA ROSEMARY (PCA)
Entity type:Individual
Prefix:
First Name:IZEGBUWA
Middle Name:ROSEMARY
Last Name:ODIASE
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9165 SPARKLEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-6352
Mailing Address - Country:US
Mailing Address - Phone:702-372-8746
Mailing Address - Fax:
Practice Address - Street 1:3975 W QUAIL AVE STE 10
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-3002
Practice Address - Country:US
Practice Address - Phone:888-226-8068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant