MEDICARE: CALISTA E EZEOKOYE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0808X	Psychiatric/Mental Health Registered Nurse	95003322	CA
2	363LF0000X	Family Nurse Practitioner	95003322	CA
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	95003322	CA

General Provider Information

NPI Number	:	1003279118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CALISTA E EZEOKOYE

Provider Business Mailing Address
First Line	:	1338 E DENWALL DR STE 200
Second Line	:
City	:	CARSON
State	:	CA
Zip	:	90746-3156
Country	:	US
Telephone Number	:	323-426-5200
Fax Number	:	323-426-5252

Provider Business Practice Location Address
First Line	:	2917 W VERNON AVE # B
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90008-4714
Country	:	US
Telephone Number	:	323-426-5200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2016
Last Update Date	:	05/03/2023

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Directions to “ CALISTA E EZEOKOYE ” Practice Location

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