Provider Demographics
NPI:1770254666
Name:MADUEKE, GRACE AMALACHUKWU
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:AMALACHUKWU
Last Name:MADUEKE
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 1:1587 COPPER MINE PSGE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-0128
Mailing Address - Country:US
Mailing Address - Phone:407-800-5830
Mailing Address - Fax:
Practice Address - Street 1:1587 COPPER MINE PSGE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-0128
Practice Address - Country:US
Practice Address - Phone:407-800-5830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28243400A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health