Healthcare Provider Details

I. General information

NPI: 1821980442
Provider Name (Legal Business Name): MR. KENNETH IHUOMA UWAOMA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2025
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15373 PARSLEY LEAF PL
FONTANA CA
92336-3396
US

IV. Provider business mailing address

15373 PARSLEY LEAF PL
FONTANA CA
92336-3396
US

V. Phone/Fax

Practice location:
  • Phone: 310-210-9734
  • Fax:
Mailing address:
  • Phone: 310-210-9734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95018634
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: