Basic Information
| Provider Information | |||||||||
| NPI: | 1366068520 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IYENGUNMWENA IREDIA | ||||||||
| FirstName: | UWAILA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 S B B KING BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014361381 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3242 CUMBERLAND TRL | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA FLDS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604611118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738145690 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2020 | ||||||||
| LastUpdateDate: | 06/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 06200631 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.