MEDICARE: IKECHUKWU OKECHUKWU

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	5598	MN

General Provider Information

NPI Number	:	1649786138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IKECHUKWU OKECHUKWU

Provider Business Mailing Address
First Line	:	1577 LEGACY PKWY E UNIT 2
Second Line	:
City	:	MAPLEWOOD
State	:	MN
Zip	:	55109-5416
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1577 LEGACY PKWY E UNIT 2
Second Line	:
City	:	MAPLEWOOD
State	:	MN
Zip	:	55109-5416
Country	:	US
Telephone Number	:	651-302-6715
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2017
Last Update Date	:	09/22/2024

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