Provider Demographics
NPI:1205221660
Name:IKWUAZOM, CYPRIAN (RN)
Entity Type:Individual
Prefix:
First Name:CYPRIAN
Middle Name:
Last Name:IKWUAZOM
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 SPANGLE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11703-3719
Mailing Address - Country:US
Mailing Address - Phone:917-617-2622
Mailing Address - Fax:
Practice Address - Street 1:445 SPANGLE DR
Practice Address - Street 2:
Practice Address - City:NORTH BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11703-3719
Practice Address - Country:US
Practice Address - Phone:917-617-2622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-02
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY621201-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse