Healthcare Provider Details

I. General information

NPI: 1679190706
Provider Name (Legal Business Name): CHUKS G EZIEFULA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2020
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4931 N CAPITOL ST NE APT 31
WASHINGTON DC
20011-6752
US

IV. Provider business mailing address

4931 N CAPITOL ST NE APT 31
WASHINGTON DC
20011-6752
US

V. Phone/Fax

Practice location:
  • Phone: 240-473-5218
  • Fax:
Mailing address:
  • Phone: 240-476-5218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR220917
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN1040687
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: