Provider Demographics
NPI:1861023236
Name:AWAKA, IFEOMA (NP)
Entity Type:Individual
Prefix:
First Name:IFEOMA
Middle Name:
Last Name:AWAKA
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 1:325 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:FALLSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:12733-5308
Mailing Address - Country:US
Mailing Address - Phone:845-434-2080
Mailing Address - Fax:
Practice Address - Street 1:325 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:FALLSBURG
Practice Address - State:NY
Practice Address - Zip Code:12733-5308
Practice Address - Country:US
Practice Address - Phone:845-434-2080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF344447-1363LP2300X
NY589194-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMA5606845OtherDEA