Provider Demographics
NPI:1871783167
Name:IYENGUNMWENA, LUCKY (RN)
Entity type:Individual
Prefix:
First Name:LUCKY
Middle Name:
Last Name:IYENGUNMWENA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2527 GLEBE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-3109
Mailing Address - Country:US
Mailing Address - Phone:718-904-4400
Mailing Address - Fax:718-931-7307
Practice Address - Street 1:1967 TURNBULL AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10473-2519
Practice Address - Country:US
Practice Address - Phone:718-842-1400
Practice Address - Fax:718-328-3349
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY572839-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse