Provider Demographics
NPI:1740994599
Name:EZEUKWU, CHINWE SANDRA
Entity type:Individual
Prefix:
First Name:CHINWE
Middle Name:SANDRA
Last Name:EZEUKWU
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 1:7643 BROOKFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CHELTENHAM
Mailing Address - State:PA
Mailing Address - Zip Code:19012-1313
Mailing Address - Country:US
Mailing Address - Phone:215-921-1112
Mailing Address - Fax:
Practice Address - Street 1:7643 BROOKFIELD RD
Practice Address - Street 2:
Practice Address - City:CHELTENHAM
Practice Address - State:PA
Practice Address - Zip Code:19012-1313
Practice Address - Country:US
Practice Address - Phone:215-921-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP026918363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty