Provider Demographics
NPI:1437959103
Name:IKOTIDEM, DOMINIC (RN)
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:IKOTIDEM
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 COVERED BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:FLEMINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08822-4902
Mailing Address - Country:US
Mailing Address - Phone:908-968-0443
Mailing Address - Fax:
Practice Address - Street 1:21 COVERED BRIDGE RD
Practice Address - Street 2:
Practice Address - City:FLEMINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08822-4902
Practice Address - Country:US
Practice Address - Phone:908-968-0443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR12970000163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator