Healthcare Provider Details

I. General information

NPI: 1770816373
Provider Name (Legal Business Name): MARY ENYI UDENGWU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
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

1200 N STATE ST
LOS ANGELES CA
90089-1001
US

V. Phone/Fax

Practice location:
  • Phone: 310-945-3350
  • Fax: 310-945-3356
Mailing address:
  • Phone: 424-338-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number19405
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: