Provider Demographics
NPI:1336362086
Name:IWUAJOKU, EDITH O (CNA)
Entity Type:Individual
Prefix:MRS
First Name:EDITH
Middle Name:O
Last Name:IWUAJOKU
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:MRS
Other - First Name:EDITH
Other - Middle Name:O
Other - Last Name:IWUAJOKU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNA
Mailing Address - Street 1:1488 ORCA WAY
Mailing Address - Street 2:1488 ORCA WAY
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89506-6608
Mailing Address - Country:US
Mailing Address - Phone:775-324-7471
Mailing Address - Fax:775-324-7471
Practice Address - Street 1:1488 ORCA WAY
Practice Address - Street 2:1488 ORCA WAY
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89506-6608
Practice Address - Country:US
Practice Address - Phone:775-324-7471
Practice Address - Fax:775-324-7471
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVEDITGILMedicaid