Provider Demographics
NPI:1780254854
Name:AMENE, NGOZIKA
Entity type:Individual
Prefix:
First Name:NGOZIKA
Middle Name:
Last Name:AMENE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VIVIANE
Other - Middle Name:
Other - Last Name:AMENE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:15850 N 35TH AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-3885
Mailing Address - Country:US
Mailing Address - Phone:702-702-2858
Mailing Address - Fax:
Practice Address - Street 1:15850 N 35TH AVE STE 1
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-3885
Practice Address - Country:US
Practice Address - Phone:702-702-2858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ09032019411208Medicaid