Provider Demographics
NPI:1487360939
Name:EDEGBE, OSARIEMEN (RN)
Entity type:Individual
Prefix:MR
First Name:OSARIEMEN
Middle Name:
Last Name:EDEGBE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 RICHARDSON RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-1239
Mailing Address - Country:US
Mailing Address - Phone:646-725-3719
Mailing Address - Fax:
Practice Address - Street 1:400 FORT HILL AVE
Practice Address - Street 2:CANANDAIGUA
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-1462
Practice Address - Country:US
Practice Address - Phone:646-725-3719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY829972163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY829972OtherNY STATE RN LICENSE