Provider Demographics
NPI:1891359519
Name:EJIMONYEUGWO, RUFUS
Entity type:Individual
Prefix:
First Name:RUFUS
Middle Name:
Last Name:EJIMONYEUGWO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8470 LIMEKILN PIKE
Mailing Address - Street 2:BUILDING 2, APT. 504
Mailing Address - City:WYNCOTE
Mailing Address - State:PA
Mailing Address - Zip Code:19095
Mailing Address - Country:US
Mailing Address - Phone:267-688-1700
Mailing Address - Fax:
Practice Address - Street 1:8470 LIMEKILN PIKE
Practice Address - Street 2:BUILDING 2, APT. 504
Practice Address - City:WYNCOTE
Practice Address - State:PA
Practice Address - Zip Code:19095
Practice Address - Country:US
Practice Address - Phone:267-688-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA103K00000X
MARN2326700163W00000X
PARN713911163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst