Healthcare Provider Details

I. General information

NPI: 1609454990
Provider Name (Legal Business Name): NNEKA CHIAGOZIEM IKPEZE PHILLIPS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 N BROADWAY STE 2
MASSAPEQUA NY
11758-1853
US

IV. Provider business mailing address

1 RESEARCH RD
RIDGE NY
11961-2701
US

V. Phone/Fax

Practice location:
  • Phone: 631-751-3000
  • Fax:
Mailing address:
  • Phone: 631-751-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number333812
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2026-04081
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: