Provider Demographics
NPI:1821331760
Name:JON-NWAKALO, REGINA (NP)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:JON-NWAKALO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11533
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12211-0533
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:427 GUY PARK AVE
Practice Address - Street 2:ADULT MENTAL HEALTH OP CLINIC
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-1064
Practice Address - Country:US
Practice Address - Phone:518-841-7341
Practice Address - Fax:518-841-7344
Is Sole Proprietor?:No
Enumeration Date:2013-03-28
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF401555-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner