Healthcare Provider Details

I. General information

NPI: 1114047735
Provider Name (Legal Business Name): NWABUEZE NNAMDI INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 CHARLES DR
JACKSON LA
70748-6135
US

IV. Provider business mailing address

3050 CHARLES DR
JACKSON LA
70748-6135
US

V. Phone/Fax

Practice location:
  • Phone: 225-634-3517
  • Fax: 225-635-5057
Mailing address:
  • Phone: 225-634-3517
  • Fax: 225-635-5057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberL12712R
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberL12712R
License Number StateLA

VIII. Authorized Official

Name: DR. STACIE N NWABUEZE
Title or Position: ADMINISTRATOR
Credential: PH.D
Phone: 225-634-3517