Provider Demographics
NPI:1770219826
Name:IDEMUDIA, AWELE
Entity Type:Individual
Prefix:
First Name:AWELE
Middle Name:
Last Name:IDEMUDIA
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 1:117 S 13TH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-4238
Mailing Address - Country:US
Mailing Address - Phone:347-866-4489
Mailing Address - Fax:
Practice Address - Street 1:26 DUMONT AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-1450
Practice Address - Country:US
Practice Address - Phone:718-667-4282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY564012163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJI18210716553512OtherDRIVER'S LICENSE