Healthcare Provider Details

I. General information

NPI: 1760982318
Provider Name (Legal Business Name): JUSTINA IKIMI NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2018
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date: 04/22/2019
Reactivation Date: 02/08/2022

III. Provider practice location address

200 S PARK RD STE 200
HOLLYWOOD FL
33021-8541
US

IV. Provider business mailing address

200 S PARK RD STE 200200S
HOLLYWOOD FL
33021-8592
US

V. Phone/Fax

Practice location:
  • Phone: 866-986-2263
  • Fax: 866-968-6339
Mailing address:
  • Phone: 866-986-2263
  • Fax: 866-986-2263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number672715
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF348931-01
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1047607
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: