Healthcare Provider Details

I. General information

NPI: 1326794223
Provider Name (Legal Business Name): MAUREEN ONYEGBULEM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11201 BENTON ST
LOMA LINDA CA
92357-3948
US

IV. Provider business mailing address

11201 BENTON ST
LOMA LINDA CA
92357-1000
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax:
Mailing address:
  • Phone: 909-825-7084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95020664
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95111167
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: