Healthcare Provider Details

I. General information

NPI: 1558985820
Provider Name (Legal Business Name): ELIZABETH CHIAMAKA OKWAMBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 08/19/2021
Certification Date: 08/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 E HUNTING PARK AVE
PHILADELPHIA PA
19124-4800
US

IV. Provider business mailing address

841 E HUNTING PARK AVE
PHILADELPHIA PA
19124-4800
US

V. Phone/Fax

Practice location:
  • Phone: 215-535-4494
  • Fax:
Mailing address:
  • Phone: 856-571-7011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR17486600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN689054
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP023660
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: