Basic Information
| Provider Information | |||||||||
| NPI: | 1922633718 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NWAKPUDA | ||||||||
| FirstName: | CECILIA | ||||||||
| MiddleName: | ADAORA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NWAKPUDA | ||||||||
| OtherFirstName: | CECILIA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 188 | ||||||||
| Address2: | |||||||||
| City: | MARANA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856530188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206824111 | ||||||||
| FaxNumber: | 5208183630 | ||||||||
| Practice Location | |||||||||
| Address1: | 899 N WILMOT RD STE B | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857111712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202901100 | ||||||||
| FaxNumber: | 5202908997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2020 | ||||||||
| LastUpdateDate: | 06/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5378685062 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 254598 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 53-78685-062 | 01 | KS | KSBN | OTHER | 088273 | 05 | AZ | MEDICAID |