Healthcare Provider Details

I. General information

NPI: 1598382921
Provider Name (Legal Business Name): AGATHA NDUDI ILOKA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

934 ATLANTIC AVE
LONG BEACH CA
90813-4515
US

IV. Provider business mailing address

934 ATLANTIC AVE
LONG BEACH CA
90813-4515
US

V. Phone/Fax

Practice location:
  • Phone: 562-437-1888
  • Fax: 562-491-1200
Mailing address:
  • Phone: 562-437-1888
  • Fax: 562-491-1200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number707827
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95017561
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: