Provider Demographics
NPI:1679923635
Name:UDENZE, KEYNADOMNICIA CHIOMA (AGNP-BC)
Entity type:Individual
Prefix:MRS
First Name:KEYNADOMNICIA
Middle Name:CHIOMA
Last Name:UDENZE
Suffix:
Gender:F
Credentials:AGNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 BENSON ROAD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-0016
Mailing Address - Country:US
Mailing Address - Phone:214-727-8681
Mailing Address - Fax:984-246-2005
Practice Address - Street 1:500 BENSON RD STE 115
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-3947
Practice Address - Country:US
Practice Address - Phone:984-246-2006
Practice Address - Fax:984-246-2005
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP131087363LA2200X
NC5009687363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP131087OtherNURSE PRACTITIONER LICENSE