Healthcare Provider Details

I. General information

NPI: 1063005403
Provider Name (Legal Business Name): THEODORA CHUKWUDI FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7445 ALLEN RD STE 270
ALLEN PARK MI
48101-1963
US

IV. Provider business mailing address

45300 CHERRY HILL RD
CANTON MI
48187-5073
US

V. Phone/Fax

Practice location:
  • Phone: 313-920-6546
  • Fax: 313-949-5793
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704249499
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: