Healthcare Provider Details

I. General information

NPI: 1306713557
Provider Name (Legal Business Name): LINDA CHIDIMMA FAGBOTE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2025
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 MAPLE AVE
LOS ANGELES CA
90014-2211
US

IV. Provider business mailing address

7175 BECK DR
RIVERSIDE CA
92503-1010
US

V. Phone/Fax

Practice location:
  • Phone: 323-274-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95147944
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: