Basic Information
| Provider Information | |||||||||
| NPI: | 1083221006 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IKECHI | ||||||||
| FirstName: | IKECHI | ||||||||
| MiddleName: | ALEX | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5325 CENTER HILL DR | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761792094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149713192 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1855 W BASELINE RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852029098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808317566 | ||||||||
| FaxNumber: | 4807752457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2020 | ||||||||
| LastUpdateDate: | 03/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 2019059252 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.