Healthcare Provider Details

I. General information

NPI: 1124264502
Provider Name (Legal Business Name): AZZA H AHMED CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2009
Last Update Date: 01/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 N UNIVERSITY ST
WEST LAFAYETTE IN
47907-2069
US

IV. Provider business mailing address

502 UNIVERSITY STREET
WEST LAFAYETTE IN
47907
US

V. Phone/Fax

Practice location:
  • Phone: 765-494-4040
  • Fax:
Mailing address:
  • Phone: 765-404-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number20082591
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: