Provider Demographics
NPI:1417746165
Name:ATIVON, KOFFI NYUIEMEDI
Entity type:Individual
Prefix:
First Name:KOFFI
Middle Name:NYUIEMEDI
Last Name:ATIVON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2990 S 93RD PLZ APT 62
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2832
Mailing Address - Country:US
Mailing Address - Phone:402-618-5006
Mailing Address - Fax:
Practice Address - Street 1:2990 S 93RD PLZ APT 62
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2832
Practice Address - Country:US
Practice Address - Phone:402-618-5006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities