Provider Demographics
NPI:1821278151
Name:ANYA, KANAYOCHUKWU KANNY JACQUELYNE (MD)
Entity Type:Individual
Prefix:
First Name:KANAYOCHUKWU KANNY
Middle Name:JACQUELYNE
Last Name:ANYA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KANAYOCHUKWU KANNY
Other - Middle Name:JACQUELYNE
Other - Last Name:ALUKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6100 HARRIS PARKWAY
Mailing Address - Street 2:SUITE 380
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132
Mailing Address - Country:US
Mailing Address - Phone:817-759-9008
Mailing Address - Fax:844-583-5414
Practice Address - Street 1:6048 LAKE WORTH BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-3706
Practice Address - Country:US
Practice Address - Phone:817-270-4243
Practice Address - Fax:817-270-4249
Is Sole Proprietor?:No
Enumeration Date:2007-11-03
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI54922-20208600000X
LAMD204301208600000X
TXN9800208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX343872301Medicaid
TX343872302Medicaid
TX387958YKPWMedicare PIN
TX343872301Medicaid