Provider Demographics
NPI:1902398787
Name:NDUKWE, FATOUMATA MOUKIR (NP)
Entity Type:Individual
Prefix:
First Name:FATOUMATA
Middle Name:MOUKIR
Last Name:NDUKWE
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 1:6581 FLORENCE LANE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111
Mailing Address - Country:US
Mailing Address - Phone:313-971-7363
Mailing Address - Fax:
Practice Address - Street 1:24450 EVERGREEN ROAD
Practice Address - Street 2:215
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2022
Practice Address - Country:US
Practice Address - Phone:248-996-8076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704267630363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704267630OtherSTATE OF MICHIGAN