Provider Demographics
NPI:1912573098
Name:ENWERE, IHEANYICHUKWU GODFREY
Entity Type:Individual
Prefix:MR
First Name:IHEANYICHUKWU
Middle Name:GODFREY
Last Name:ENWERE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:938 DERRICK ADKINS LN
Mailing Address - Street 2:
Mailing Address - City:WEST HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11552-3914
Mailing Address - Country:US
Mailing Address - Phone:646-242-5440
Mailing Address - Fax:
Practice Address - Street 1:938 DERRICK ADKINS LN
Practice Address - Street 2:
Practice Address - City:WEST HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11552-3914
Practice Address - Country:US
Practice Address - Phone:646-242-5440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-31
Last Update Date:2021-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY652069163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY660374570Medicaid