Healthcare Provider Details

I. General information

NPI: 1568641868
Provider Name (Legal Business Name): IVY NJOLOMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2007
Last Update Date: 11/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14248 SAN BENITO CT
FONTANA CA
92336-3781
US

IV. Provider business mailing address

14248 SAN BENITO CT
FONTANA CA
92336-3781
US

V. Phone/Fax

Practice location:
  • Phone: 909-427-0218
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number450230
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: