Provider Demographics
NPI:1588865539
Name:NKWONTA, VIVIAN CHIZOBA (MD)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:CHIZOBA
Last Name:NKWONTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16251 SYLVESTER RD SW
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-3017
Mailing Address - Country:US
Mailing Address - Phone:253-426-6341
Mailing Address - Fax:253-858-5436
Practice Address - Street 1:16251 SYLVESTER RD SW
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-3017
Practice Address - Country:US
Practice Address - Phone:253-426-6341
Practice Address - Fax:253-858-5436
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60034300207R00000X
OH57-010767207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1092206Medicaid
WA0250081OtherSTATE L&I