Healthcare Provider Details

I. General information

NPI: 1215745005
Provider Name (Legal Business Name): IZODUWA LUCINDA EKUNWE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: IZODUWA LUCINDA EKUNWE NP

II. Dates (important events)

Enumeration Date: 12/25/2024
Last Update Date: 12/25/2024
Certification Date: 12/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 DUNLEITH WAY
CLINTON MS
39056-5456
US

IV. Provider business mailing address

131 DUNLEITH WAY
CLINTON MS
39056-5456
US

V. Phone/Fax

Practice location:
  • Phone: 601-718-7008
  • Fax:
Mailing address:
  • Phone: 601-718-7008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF10240227
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number915702
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: