Provider Demographics
NPI:1679067425
Name:ORISAKWE, DOMINICA NGOZI
Entity Type:Individual
Prefix:
First Name:DOMINICA
Middle Name:NGOZI
Last Name:ORISAKWE
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 1:17400 TERRY AVE
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33948-1373
Mailing Address - Country:US
Mailing Address - Phone:941-766-8638
Mailing Address - Fax:
Practice Address - Street 1:3390 TAMIAMI TRL STE 204
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8162
Practice Address - Country:US
Practice Address - Phone:941-391-5495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3209032363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner