Healthcare Provider Details

I. General information

NPI: 1851853535
Provider Name (Legal Business Name): OKWUCHUKWU INNOCENT UDEMBA PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 WEBSTER AVE STE 3
BRONX NY
10456-5205
US

IV. Provider business mailing address

1150 WEBSTER AVE STE 3
BRONX NY
10456-5205
US

V. Phone/Fax

Practice location:
  • Phone: 347-271-7666
  • Fax:
Mailing address:
  • Phone: 347-271-7666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF405802-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number766300
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: