Provider Demographics
NPI:1316069248
Name:NWANKUDU, AMADI EZEGO
Entity type:Individual
Prefix:
First Name:AMADI
Middle Name:EZEGO
Last Name:NWANKUDU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E CHEVES ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-2526
Mailing Address - Country:US
Mailing Address - Phone:843-317-4089
Mailing Address - Fax:843-317-4096
Practice Address - Street 1:730 S DARGAN ST APT 4D
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2567
Practice Address - Country:US
Practice Address - Phone:843-661-4718
Practice Address - Fax:843-661-4722
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC376241Medicaid
SC3337Medicare ID - Type Unspecified