Provider Demographics
NPI:1962961805
Name:NWACHUKU, IKENNA BEN
Entity type:Individual
Prefix:
First Name:IKENNA
Middle Name:BEN
Last Name:NWACHUKU
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 1:1200 N STATE ST # GH3900
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1029
Mailing Address - Country:US
Mailing Address - Phone:323-409-7409
Mailing Address - Fax:
Practice Address - Street 1:1200 N STATE ST # GH3900
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1029
Practice Address - Country:US
Practice Address - Phone:323-409-7409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program