Provider Demographics
NPI:1386377612
Name:NWACHUKWU, JOECOLINE
Entity type:Individual
Prefix:
First Name:JOECOLINE
Middle Name:
Last Name:NWACHUKWU
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 1:1550 N D ST STE D
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-4720
Mailing Address - Country:US
Mailing Address - Phone:909-688-6151
Mailing Address - Fax:951-399-2038
Practice Address - Street 1:1550 N D ST STE D
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405-4720
Practice Address - Country:US
Practice Address - Phone:909-688-6151
Practice Address - Fax:951-399-2038
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-05
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95021528363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health