Healthcare Provider Details

I. General information

NPI: 1609047166
Provider Name (Legal Business Name): OSAMAMWODE SUNDAY OGBEIWI NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2008
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W CENTRAL AVE SUITE B120
BREA CA
92821-7515
US

IV. Provider business mailing address

954 BARBARA LN
POMONA CA
91767-4118
US

V. Phone/Fax

Practice location:
  • Phone: 714-709-3154
  • Fax:
Mailing address:
  • Phone: 714-709-3154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17752
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number17752
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: