Healthcare Provider Details

I. General information

NPI: 1710458096
Provider Name (Legal Business Name): NNENNAYA OGBULORIE OKORONKWO PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2018
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9680 CITRUS AVE
FONTANA CA
92335-5571
US

IV. Provider business mailing address

6952 ABIGAIL LN
FONTANA CA
92336-5769
US

V. Phone/Fax

Practice location:
  • Phone: 909-357-7600
  • Fax: 909-357-7649
Mailing address:
  • Phone: 909-333-1003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95010504
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: