Basic Information
Provider Information | |||||||||
NPI: | 1679801633 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OBI | ||||||||
FirstName: | THECLA | ||||||||
MiddleName: | IHUAKU | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 50 S B B KING BLVD # 100 | ||||||||
Address2: |   | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381032626 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9014361381 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 322 LAKE AVE | ||||||||
Address2: | BROWN SQUARE CENTER | ||||||||
City: | ROCHESTER | ||||||||
State: | NY | ||||||||
PostalCode: | 146087141 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5852546480 | ||||||||
FaxNumber: | 5852541092 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/02/2009 | ||||||||
LastUpdateDate: | 09/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 576732 | NY | N |   | Nursing Service Providers | Registered Nurse |   | 363LF0000X | 338190 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 03734892 | 05 | NY |   | MEDICAID | J400240135 | 01 | NY | MEDICARE PTAN | OTHER |