Healthcare Provider Details

I. General information

NPI: 1700134681
Provider Name (Legal Business Name): CHINYELU LILY FAFOWORA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 08/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21038 NASHVILLE BLVD
CAMBRIA HTS NY
11411-1043
US

IV. Provider business mailing address

21038 NASHVILLE BLVD
CAMBRIA HTS NY
11411-1043
US

V. Phone/Fax

Practice location:
  • Phone: 646-262-0168
  • Fax:
Mailing address:
  • Phone: 646-262-0168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1114570
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: