Healthcare Provider Details

I. General information

NPI: 1356119903
Provider Name (Legal Business Name): HERITAGE HEALTH AND WELLNESS NP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2023
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

879 W 190TH ST STE 400
GARDENA CA
90248-4223
US

IV. Provider business mailing address

879 W 190TH ST STE 400
GARDENA CA
90248-4223
US

V. Phone/Fax

Practice location:
  • Phone: 818-922-7339
  • Fax: 818-922-7337
Mailing address:
  • Phone: 818-922-7339
  • Fax: 818-922-7337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: IFEOMA CYNTHIA ANIEMEKA
Title or Position: NURSE PRACTITIONER
Credential: MD
Phone: 310-921-0196