Healthcare Provider Details

I. General information

NPI: 1699410746
Provider Name (Legal Business Name): NDUBUISI CHIMEZIE OBIOHA NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2022
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18836 PEPPERDINE DR
CARSON CA
90746-3904
US

IV. Provider business mailing address

2917 W VERNON AVE STE B
LOS ANGELES CA
90008-4714
US

V. Phone/Fax

Practice location:
  • Phone: 323-788-4274
  • Fax:
Mailing address:
  • Phone: 323-426-5200
  • Fax: 323-426-5252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP95020670
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: