Provider Demographics
NPI:1205247244
Name:IFEZUE, NWADIUTOR O (FNP)
Entity type:Individual
Prefix:MRS
First Name:NWADIUTOR
Middle Name:O
Last Name:IFEZUE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 806112
Mailing Address - Street 2:STE 109
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-4122
Mailing Address - Country:US
Mailing Address - Phone:773-933-9300
Mailing Address - Fax:773-933-9302
Practice Address - Street 1:22621 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-1612
Practice Address - Country:US
Practice Address - Phone:708-945-1712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-13
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041290058363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily