Provider Demographics
NPI:1295295038
Name:MADU, IFEANYI C (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MR
First Name:IFEANYI
Middle Name:C
Last Name:MADU
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:MR
Other - First Name:IFEANYI
Other - Middle Name:JOHN
Other - Last Name:MADU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:1470 E CALVADA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:PAHRUMP
Mailing Address - State:NV
Mailing Address - Zip Code:89048-3906
Mailing Address - Country:US
Mailing Address - Phone:775-210-8333
Mailing Address - Fax:775-346-9158
Practice Address - Street 1:1470 E CALVADA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048-3906
Practice Address - Country:US
Practice Address - Phone:775-210-8338
Practice Address - Fax:775-346-9158
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV818778363LG0600X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology