Provider Demographics
NPI:1588624027
Name:CHUKWUDOLUE, ANGELA (NP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:CHUKWUDOLUE
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 1:2510 W DUNLAP AVE
Mailing Address - Street 2:STE 290
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-2759
Mailing Address - Country:US
Mailing Address - Phone:602-789-0344
Mailing Address - Fax:602-789-8389
Practice Address - Street 1:2145 W SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4715
Practice Address - Country:US
Practice Address - Phone:480-835-3000
Practice Address - Fax:480-512-6257
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP1136363LA2200X
AZAP1137363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ536914Medicaid
AZZ128358OtherMEDICARE PTAN
AZ536914Medicaid
AZZ106522Medicare ID - Type Unspecified