Provider Demographics
NPI:1912281593
Name:EJINKONYE, GRACE NWAMAKA
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:NWAMAKA
Last Name:EJINKONYE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NONE
Other - Middle Name:NONE
Other - Last Name:DON,T HAVE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3000 OCEAN PKWY
Mailing Address - Street 2:#3F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-8374
Mailing Address - Country:US
Mailing Address - Phone:718-324-3013
Mailing Address - Fax:
Practice Address - Street 1:3000 OCEAN PKWY
Practice Address - Street 2:#3F
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-8374
Practice Address - Country:US
Practice Address - Phone:718-324-3013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY296209-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse