Healthcare Provider Details

I. General information

NPI: 1811719511
Provider Name (Legal Business Name): INNOCENT IDUSUYI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2024
Last Update Date: 11/10/2024
Certification Date: 11/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2766 KEATS AVE
CLOVIS CA
93611-6965
US

IV. Provider business mailing address

2766 KEATS AVE
CLOVIS CA
93611-6965
US

V. Phone/Fax

Practice location:
  • Phone: 559-701-5394
  • Fax:
Mailing address:
  • Phone: 559-701-5394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95136042
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: