Provider Demographics
NPI:1205597887
Name:ETUKUDOH, AKANINYENE (PMHNP)
Entity type:Individual
Prefix:
First Name:AKANINYENE
Middle Name:
Last Name:ETUKUDOH
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:VICTOR
Other - Middle Name:
Other - Last Name:ETUKUDOH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1095 E INDIAN SCHOOL RD STE 700
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-4846
Mailing Address - Country:US
Mailing Address - Phone:602-515-9893
Mailing Address - Fax:
Practice Address - Street 1:1095 E INDIAN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-4801
Practice Address - Country:US
Practice Address - Phone:623-439-7645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2672512084P0802X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty