Healthcare Provider Details

I. General information

NPI: 1437514098
Provider Name (Legal Business Name): IFESONYE EMILOJU OKWUCHI NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2015
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4430 MISSOURI AVE
FORT LEONARD WOOD MO
65473-9098
US

IV. Provider business mailing address

3123 FONTANA BLVD
ROCKWALL TX
75032-4400
US

V. Phone/Fax

Practice location:
  • Phone: 573-596-0417
  • Fax:
Mailing address:
  • Phone: 806-283-0352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP129463
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: