Healthcare Provider Details

I. General information

NPI: 1265026892
Provider Name (Legal Business Name): UGO UDEOCHU NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2021
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 W HAWTHORNE AVE FL 2
VALLEY STREAM NY
11580-6223
US

IV. Provider business mailing address

15038 115TH DR
JAMAICA NY
11434-1502
US

V. Phone/Fax

Practice location:
  • Phone: 516-569-6600
  • Fax:
Mailing address:
  • Phone: 718-496-0634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number403420
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: