Healthcare Provider Details

I. General information

NPI: 1710499181
Provider Name (Legal Business Name): JULIANA CHIOMA NWACHUKWU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2017
Last Update Date: 10/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 MAIN ST
TURTLE LAKE ND
58575-4001
US

IV. Provider business mailing address

24 RAILROAD AVENUE, SUITE #16
RAY ND
58849
US

V. Phone/Fax

Practice location:
  • Phone: 701-448-2054
  • Fax:
Mailing address:
  • Phone: 701-448-2054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR45102
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: