Healthcare Provider Details

I. General information

NPI: 1396654281
Provider Name (Legal Business Name): LESLIE EMWINMA EVBUOMWAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1642 W AVENUE J
LANCASTER CA
93534-2814
US

IV. Provider business mailing address

40932 OAKVIEW LN
PALMDALE CA
93551-2775
US

V. Phone/Fax

Practice location:
  • Phone: 203-768-7549
  • Fax:
Mailing address:
  • Phone: 203-768-7549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95034380
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95034380
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: