Provider Demographics
NPI:1366068520
Name:IYENGUNMWENA IREDIA, UWAILA
Entity type:Individual
Prefix:MRS
First Name:UWAILA
Middle Name:
Last Name:IYENGUNMWENA IREDIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 S B B KING BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2626
Mailing Address - Country:US
Mailing Address - Phone:901-436-1381
Mailing Address - Fax:
Practice Address - Street 1:3242 CUMBERLAND TRL
Practice Address - Street 2:
Practice Address - City:OLYMPIA FLDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1118
Practice Address - Country:US
Practice Address - Phone:773-814-5690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL06200631363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner