Provider Demographics
NPI:1326640517
Name:EDEM, IKANKE
Entity Type:Individual
Prefix:
First Name:IKANKE
Middle Name:
Last Name:EDEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7308 POWHATAN ST
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-1234
Mailing Address - Country:US
Mailing Address - Phone:202-367-1480
Mailing Address - Fax:
Practice Address - Street 1:7308 POWHATAN ST
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-1234
Practice Address - Country:US
Practice Address - Phone:202-367-1480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR194291363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner