Healthcare Provider Details

I. General information

NPI: 1336831718
Provider Name (Legal Business Name): STELLA IJEOMA NWACHUKWU I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2023
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 IRVINGTON AVE
HILLSIDE NJ
07205-3105
US

IV. Provider business mailing address

813 IRVINGTON AVENUE
HILLSIDE NJ
07205
US

V. Phone/Fax

Practice location:
  • Phone: 973-444-8636
  • Fax:
Mailing address:
  • Phone: 973-444-8636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ01483900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: