Healthcare Provider Details

I. General information

NPI: 1902717630
Provider Name (Legal Business Name): NNAMDI OKWUKAOGU RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 BROAD ST APT 404
LYNN MA
01902-5095
US

IV. Provider business mailing address

113 BROAD ST APT 404
LYNN MA
01902-5095
US

V. Phone/Fax

Practice location:
  • Phone: 781-299-3732
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License NumberRN2372032
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: