Healthcare Provider Details

I. General information

NPI: 1356056030
Provider Name (Legal Business Name): MARK ANWULI AWANYAI JR. NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2023
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5603 CARFAX AVE
LAKEWOOD CA
90713-1253
US

IV. Provider business mailing address

5603 CARFAX AVE
LAKEWOOD CA
90713-1253
US

V. Phone/Fax

Practice location:
  • Phone: 725-502-1061
  • Fax: 562-512-4871
Mailing address:
  • Phone: 562-378-3798
  • Fax: 562-512-4871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN10034774
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95037463
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95100194
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number331435
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: