Provider Demographics
NPI:1710509740
Name:MADUKA, KELECHI
Entity Type:Individual
Prefix:
First Name:KELECHI
Middle Name:
Last Name:MADUKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4229 GLENHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042-6120
Mailing Address - Country:US
Mailing Address - Phone:469-209-3783
Mailing Address - Fax:972-918-5166
Practice Address - Street 1:4229 GLENHAVEN DR
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-6120
Practice Address - Country:US
Practice Address - Phone:469-209-3783
Practice Address - Fax:972-918-5166
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX789766163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator