Provider Demographics
NPI:1538628342
Name:IDUMWONYI, HENRIETTA IMADE (BSN, RN)
Entity type:Individual
Prefix:MISS
First Name:HENRIETTA
Middle Name:IMADE
Last Name:IDUMWONYI
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:MA
Mailing Address - Zip Code:02322-1532
Mailing Address - Country:US
Mailing Address - Phone:617-749-6062
Mailing Address - Fax:
Practice Address - Street 1:66 CANAL ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2002
Practice Address - Country:US
Practice Address - Phone:617-371-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2330913163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse