Provider Demographics
NPI:1194356733
Name:EZENWATA, MUNACHI QUEENA (FNP, PMHNP)
Entity Type:Individual
Prefix:
First Name:MUNACHI
Middle Name:QUEENA
Last Name:EZENWATA
Suffix:
Gender:F
Credentials:FNP, PMHNP
Other - Prefix:
Other - First Name:MUNACHI
Other - Middle Name:QUEENA
Other - Last Name:OKORO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 30771
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89173-0771
Mailing Address - Country:US
Mailing Address - Phone:630-795-9110
Mailing Address - Fax:
Practice Address - Street 1:400 SHADOW LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4363
Practice Address - Country:US
Practice Address - Phone:702-805-2069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-02
Last Update Date:2024-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV824487363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily