Provider Demographics
NPI:1891680542
Name:IBENEME, CHIDALU N (ASSISTANT PHYSICIAN)
Entity type:Individual
Prefix:
First Name:CHIDALU
Middle Name:N
Last Name:IBENEME
Suffix:
Gender:F
Credentials:ASSISTANT PHYSICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:2900 OLD 63 S APT 102
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-5374
Mailing Address - Country:US
Mailing Address - Phone:419-204-9575
Mailing Address - Fax:
Practice Address - Street 1:13013 FULLER AVE STE A
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030-2687
Practice Address - Country:US
Practice Address - Phone:419-204-9575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-12
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2024048683363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant