Chinenye Ebele Ezeudemba

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

License

61589892 Issued in WA

Practice address

4600 Touchton Rd E Ste 150
Jacksonville, FL 32246-8299

Phone

(183) 359-8642

NPI assigned

Jun 16, 2021

Last updated

Dec 14, 2024By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1623801600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1734134400000",
    "number": "1366010324",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2040 CAREFREE LN",
            "city": "ANTIOCH",
            "state": "TN",
            "postal_code": "370133583",
            "telephone_number": "615-420-5634"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4600 TOUCHTON RD E STE 150",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322468299",
            "telephone_number": "183-359-8642"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2040 Carefree Ln",
            "address_purpose": "LOCATION",
            "city": "Antioch",
            "state": "TN",
            "postal_code": "370133583",
            "country_code": "US",
            "telephone_number": "615-420-5634",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "EZEUDEMBA",
        "first_name": "CHINENYE",
        "middle_name": "EBELE",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2021-06-16",
        "last_updated": "2024-12-14",
        "certification_date": "2024-12-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "FL",
            "license": "11019685",
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "TN",
            "license": "29479",
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "WA",
            "license": "61589892",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "other",
            "affiliation": "N",
            "endpointDescription": "other",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "other",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "other",
            "address_1": "2040 Carefree Ln",
            "city": "Antioch",
            "state": "TN",
            "country_code": "US",
            "postal_code": "370133583",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Psychiatric/Mental Health Nurse Practitioner in Jacksonville, FL
• Providers in Jacksonville, FL by specialty
• Psychiatric/Mental Health Nurse Practitioner in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 14, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.