Provider Demographics
NPI:1134570807
Name:MBELU, NKEMAKONAM
Entity type:Individual
Prefix:
First Name:NKEMAKONAM
Middle Name:
Last Name:MBELU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 WASHINGTON ST
Mailing Address - Street 2:#614
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-8253
Mailing Address - Country:US
Mailing Address - Phone:954-549-9911
Mailing Address - Fax:
Practice Address - Street 1:3500 WASHINGTON ST
Practice Address - Street 2:#614
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-8253
Practice Address - Country:US
Practice Address - Phone:954-549-9911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9320570363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP 9320570OtherSTATE OF FLORIDA, DEPARTMENT OF HEALTH, DIVISION OF QUALITY ASSURANCE