Provider Demographics
NPI:1316659972
Name:IKWUDIRIM, SAMPA
Entity type:Individual
Prefix:
First Name:SAMPA
Middle Name:
Last Name:IKWUDIRIM
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SAMPA
Other - Middle Name:
Other - Last Name:MUSONDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:14 DELORENZO DR
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-2706
Mailing Address - Country:US
Mailing Address - Phone:617-792-1371
Mailing Address - Fax:
Practice Address - Street 1:14 DELORENZO DR
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-2706
Practice Address - Country:US
Practice Address - Phone:617-792-1371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2329893163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6177921371Medicaid