Healthcare Provider Details

I. General information

NPI: 1750855284
Provider Name (Legal Business Name): IFEOMA ROSE OKONGWU RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2019
Last Update Date: 01/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9808 VENICE BLVD STE 700
CULVER CITY CA
90232-6824
US

IV. Provider business mailing address

9808 VENICE BLVD STE 700
CULVER CITY CA
90232-6824
US

V. Phone/Fax

Practice location:
  • Phone: 310-945-3350
  • Fax: 310-945-3356
Mailing address:
  • Phone: 310-945-3350
  • Fax: 310-945-3356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95044192
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: