Provider Demographics
NPI:1942572540
Name:AHUMARAEZE, CHYNWE CELESTINE (ARNP)
Entity Type:Individual
Prefix:MR
First Name:CHYNWE
Middle Name:CELESTINE
Last Name:AHUMARAEZE
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17844 E 23RD ST S
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-1840
Mailing Address - Country:US
Mailing Address - Phone:816-254-3652
Mailing Address - Fax:816-254-9243
Practice Address - Street 1:17844 E 23RD ST S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-1840
Practice Address - Country:US
Practice Address - Phone:816-254-3652
Practice Address - Fax:816-254-9243
Is Sole Proprietor?:No
Enumeration Date:2012-01-30
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012001791363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1942572540Medicaid
MO474A00017Medicare PIN
MON22000006Medicare PIN