Healthcare Provider Details

I. General information

NPI: 1699419366
Provider Name (Legal Business Name): CAROLINE NAMIREMBE MAYENGO DNP, AGPNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 S WESTERN AVE
LOS ANGELES CA
90006-5801
US

IV. Provider business mailing address

1655 S WESTERN AVE
LOS ANGELES CA
90006-5801
US

V. Phone/Fax

Practice location:
  • Phone: 323-737-5200
  • Fax: 323-737-5400
Mailing address:
  • Phone: 323-737-5200
  • Fax: 323-737-5400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95020746
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number95020746
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95020746
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95020746
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: