Provider Demographics
NPI:1568942092
Name:NYIRASUKU, IMMACULEE (ARNP)
Entity Type:Individual
Prefix:
First Name:IMMACULEE
Middle Name:
Last Name:NYIRASUKU
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 BEAR RUN BLVD
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-7334
Mailing Address - Country:US
Mailing Address - Phone:414-331-0919
Mailing Address - Fax:
Practice Address - Street 1:3205 BEAR RUN BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-7334
Practice Address - Country:US
Practice Address - Phone:414-331-0919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9365710363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner