Healthcare Provider Details

I. General information

NPI: 1679270979
Provider Name (Legal Business Name): CHINEDU IBEMADU APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2023
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 OLD KINGS HWY S FL 1
DARIEN CT
06820-4526
US

IV. Provider business mailing address

64 PARKVIEW DR
AVON CT
06001-3453
US

V. Phone/Fax

Practice location:
  • Phone: 800-465-3203
  • Fax:
Mailing address:
  • Phone: 203-214-5586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11594
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: