Provider Demographics
NPI:1174925648
Name:GBOMITA, WINIFRED OLUCHI (CRNP)
Entity type:Individual
Prefix:
First Name:WINIFRED
Middle Name:OLUCHI
Last Name:GBOMITA
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:WINIFRED
Other - Middle Name:OLUCHI
Other - Last Name:IWU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18 EDGEMOOR RD
Mailing Address - Street 2:
Mailing Address - City:CHELTENHAM
Mailing Address - State:PA
Mailing Address - Zip Code:19012-1817
Mailing Address - Country:US
Mailing Address - Phone:856-237-7095
Mailing Address - Fax:
Practice Address - Street 1:3535 MARKET ST STE 100
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-3376
Practice Address - Country:US
Practice Address - Phone:800-873-8845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP013598363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily