Provider Demographics
NPI:1124787072
Name:NWACHUKWU, IHUOMA
Entity type:Individual
Prefix:
First Name:IHUOMA
Middle Name:
Last Name:NWACHUKWU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 CRYSTAL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-3798
Mailing Address - Country:US
Mailing Address - Phone:214-753-6044
Mailing Address - Fax:
Practice Address - Street 1:341 CRYSTAL LAKE DR
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-3798
Practice Address - Country:US
Practice Address - Phone:214-753-6044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1059878363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health