Provider Demographics
NPI:1073062287
Name:NWANKWO, IFEDIMA (LAT, ATC, PTA)
Entity Type:Individual
Prefix:
First Name:IFEDIMA
Middle Name:
Last Name:NWANKWO
Suffix:
Gender:F
Credentials:LAT, ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 BOAS ST APT 1209
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17102-1313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:660 BOAS ST APT 1209
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17102-1313
Practice Address - Country:US
Practice Address - Phone:202-802-2552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-28
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00008912255A2300X
PATE013262225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer