Provider Demographics
NPI:1194338160
Name:EGWU, QUEENETH N
Entity type:Individual
Prefix:
First Name:QUEENETH
Middle Name:N
Last Name:EGWU
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 NICKLAUS LN
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60083-8944
Mailing Address - Country:US
Mailing Address - Phone:847-263-7244
Mailing Address - Fax:
Practice Address - Street 1:3522 W LISBON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-1953
Practice Address - Country:US
Practice Address - Phone:414-935-8000
Practice Address - Fax:414-344-3396
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021726363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily