Healthcare Provider Details

I. General information

NPI: 1295295038
Provider Name (Legal Business Name): IFEANYI C MADU NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: IFEANYI JOHN MADU APRN

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 02/19/2026
Certification Date: 02/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 W LAKE MEAD PKWY STE 120
HENDERSON NV
89015-7417
US

IV. Provider business mailing address

6101 BLUE LAGOON DR STE 200
MIAMI FL
33126-3168
US

V. Phone/Fax

Practice location:
  • Phone: 725-220-8477
  • Fax: 833-749-0360
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number818778
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number818778
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: