Healthcare Provider Details

I. General information

NPI: 1114670882
Provider Name (Legal Business Name): ADA GRACE OBAH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 E ANAHEIM ST STE B
LONG BEACH CA
90804-3419
US

IV. Provider business mailing address

2100 E ANAHEIM ST STE B
LONG BEACH CA
90804-3419
US

V. Phone/Fax

Practice location:
  • Phone: 562-478-4102
  • Fax: 562-478-4105
Mailing address:
  • Phone: 562-478-4102
  • Fax: 562-478-4105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number95019561
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: