Healthcare Provider Details

I. General information

NPI: 1639959166
Provider Name (Legal Business Name): NNENNAYA O AGWU APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2023
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N MAIN ST STE 500
GREENVILLE SC
29601-2129
US

IV. Provider business mailing address

1601 GREEN STREET COLUMBIA
COLUMBIA SC
29208-0001
US

V. Phone/Fax

Practice location:
  • Phone: 800-275-3243
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number29072
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberGAA-NP002631
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number29072
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: