Healthcare Provider Details

I. General information

NPI: 1215276050
Provider Name (Legal Business Name): CYNTHIA E OKOEGUALE PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2013
Last Update Date: 01/28/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5756 RIVERWOOD LN
FONTANA CA
92336-5632
US

IV. Provider business mailing address

5756 RIVERWOOD LN
FONTANA CA
92336-5632
US

V. Phone/Fax

Practice location:
  • Phone: 909-440-0288
  • Fax:
Mailing address:
  • Phone: 909-440-0288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number801593
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95033732
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: