Provider Demographics
NPI:1669029096
Name:AMENYO, AKOSSIWA (HAIR LOSS SPECIALIST)
Entity Type:Individual
Prefix:
First Name:AKOSSIWA
Middle Name:
Last Name:AMENYO
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 S LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2663
Mailing Address - Country:US
Mailing Address - Phone:618-401-6359
Mailing Address - Fax:
Practice Address - Street 1:625 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-2663
Practice Address - Country:US
Practice Address - Phone:618-401-6359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management