Healthcare Provider Details

I. General information

NPI: 1629703608
Provider Name (Legal Business Name): HENRIETHA UGOCHI IWOBI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2022
Last Update Date: 07/22/2022
Certification Date: 07/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13300 HAWTHORNE BLVD
HAWTHORNE CA
90250
US

IV. Provider business mailing address

13532 1/2 CHADRON AVE
HAWTHORNE CA
90250-7822
US

V. Phone/Fax

Practice location:
  • Phone: 424-365-3031
  • Fax:
Mailing address:
  • Phone: 424-200-9015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95019958
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: