Provider Demographics
NPI:1316649379
Name:MBACHU, CHISOM MIRABEL
Entity type:Individual
Prefix:
First Name:CHISOM
Middle Name:MIRABEL
Last Name:MBACHU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5706 ALBER AVE
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129-3331
Mailing Address - Country:US
Mailing Address - Phone:440-482-3129
Mailing Address - Fax:
Practice Address - Street 1:6930 TREELINE DR
Practice Address - Street 2:
Practice Address - City:BRECKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44141-3371
Practice Address - Country:US
Practice Address - Phone:312-761-3057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0032659363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily