Provider Demographics
NPI:1962960930
Name:ADIBE, ELSIE OGE IZUNWANNE (APRN)
Entity type:Individual
Prefix:
First Name:ELSIE
Middle Name:OGE IZUNWANNE
Last Name:ADIBE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 MAIN ST STE 300
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4342
Mailing Address - Country:US
Mailing Address - Phone:508-586-2660
Mailing Address - Fax:
Practice Address - Street 1:MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-4342
Practice Address - Country:US
Practice Address - Phone:253-968-2252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2022-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX946868163W00000X
TX1028699363LP0808X
MARN2330477363LP0808X
WAAP61295115363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse