Provider Demographics
NPI:1710704077
Name:AKHIBI-IREO, ETHEL
Entity type:Individual
Prefix:
First Name:ETHEL
Middle Name:
Last Name:AKHIBI-IREO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-1908
Mailing Address - Country:US
Mailing Address - Phone:617-756-1701
Mailing Address - Fax:
Practice Address - Street 1:333 ELM ST STE 310
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-4530
Practice Address - Country:US
Practice Address - Phone:508-663-3852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-26
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN265490363LP0808X
MA1710704077363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner