Provider Demographics
NPI:1780289561
Name:NKEM, VICTOR
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:NKEM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8708 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-1351
Mailing Address - Country:US
Mailing Address - Phone:520-302-6217
Mailing Address - Fax:
Practice Address - Street 1:18427 N 33RD AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-1050
Practice Address - Country:US
Practice Address - Phone:843-424-7508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ249812376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1447710652Medicaid
AZ1972149078Medicaid