Provider Demographics
NPI:1316793318
Name:IDEHEN, ESOHE MARIAN
Entity type:Individual
Prefix:
First Name:ESOHE
Middle Name:MARIAN
Last Name:IDEHEN
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 1:4 CAMBO ST
Mailing Address - Street 2:4 CAMBO STREET
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5863
Mailing Address - Country:US
Mailing Address - Phone:857-247-3739
Mailing Address - Fax:
Practice Address - Street 1:4 CAMBO ST
Practice Address - Street 2:4 CAMBO STREET
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5863
Practice Address - Country:US
Practice Address - Phone:857-247-3739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA98489164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse