Provider Demographics
NPI:1992339741
Name:OHAYA, BONIFACE EMEKA (LPN)
Entity type:Individual
Prefix:MR
First Name:BONIFACE
Middle Name:EMEKA
Last Name:OHAYA
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 BIRCH DR
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-3404
Mailing Address - Country:US
Mailing Address - Phone:857-719-3306
Mailing Address - Fax:
Practice Address - Street 1:22 BIRCH DR
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-3404
Practice Address - Country:US
Practice Address - Phone:857-719-3306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-02
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN94695164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANAMedicaid