Provider Demographics
NPI:1528750205
Name:IFEANYICHUKWU, GENEVIEVE (NP)
Entity type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:
Last Name:IFEANYICHUKWU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6340 SECURITY BLVD STE B56
Mailing Address - Street 2:
Mailing Address - City:WOODLAWN
Mailing Address - State:MD
Mailing Address - Zip Code:21207-5173
Mailing Address - Country:US
Mailing Address - Phone:443-531-4264
Mailing Address - Fax:
Practice Address - Street 1:6340 SECURITY BLVD STE B56
Practice Address - Street 2:
Practice Address - City:WOODLAWN
Practice Address - State:MD
Practice Address - Zip Code:21207-5173
Practice Address - Country:US
Practice Address - Phone:443-531-4264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR218823363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily