Provider Demographics
NPI:1306318712
Name:EBENMELU, CHIDIOGO (APRN)
Entity type:Individual
Prefix:
First Name:CHIDIOGO
Middle Name:
Last Name:EBENMELU
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6706 LAGUNA TRACE ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-2066
Mailing Address - Country:US
Mailing Address - Phone:347-869-2923
Mailing Address - Fax:
Practice Address - Street 1:6706 LAGUNA TRACE ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-2066
Practice Address - Country:US
Practice Address - Phone:347-869-2923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-23
Last Update Date:2018-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAG10180235363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology