Provider Demographics
NPI:1962279067
Name:ANYABOLU, IKENNA CHIDUM
Entity type:Individual
Prefix:
First Name:IKENNA
Middle Name:CHIDUM
Last Name:ANYABOLU
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 1:10727 RIVER WALK DR
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-5524
Mailing Address - Country:US
Mailing Address - Phone:513-442-6044
Mailing Address - Fax:
Practice Address - Street 1:3513 OLD HOLLY DR
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-1933
Practice Address - Country:US
Practice Address - Phone:513-442-6044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1143408363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health