Healthcare Provider Details

I. General information

NPI: 1609624956
Provider Name (Legal Business Name): VANITY MCKENZIE ESELEBOR PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VANITY MCKENZIE

II. Dates (important events)

Enumeration Date: 05/10/2024
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12566 VALLEY VIEW ST
GARDEN GROVE CA
92845-2006
US

IV. Provider business mailing address

8697 LA MESA BLVD STE C521
LA MESA CA
91942-9565
US

V. Phone/Fax

Practice location:
  • Phone: 999-999-9999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95041442
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number95359132
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: