Provider Demographics
NPI:1396831954
Name:IKWUEME, SERAPHINE (NP)
Entity Type:Individual
Prefix:MS
First Name:SERAPHINE
Middle Name:
Last Name:IKWUEME
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2926 MOUNTAIN INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-3012
Mailing Address - Country:US
Mailing Address - Phone:877-796-3363
Mailing Address - Fax:877-796-3386
Practice Address - Street 1:2926 MOUNTAIN INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-3012
Practice Address - Country:US
Practice Address - Phone:877-796-3363
Practice Address - Fax:877-796-3386
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF304012363LP0808X
GARN171553363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY00246075Medicaid