Provider Demographics
NPI:1215202650
Name:NKEMAKOLAM, NKENNA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:NKENNA
Middle Name:
Last Name:NKEMAKOLAM
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-2333
Mailing Address - Country:US
Mailing Address - Phone:347-248-7160
Mailing Address - Fax:347-248-7160
Practice Address - Street 1:2460 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-3117
Practice Address - Country:US
Practice Address - Phone:718-226-5619
Practice Address - Fax:718-226-5620
Is Sole Proprietor?:No
Enumeration Date:2012-03-19
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY504531163W00000X
NYF337122-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse