Healthcare Provider Details

I. General information

NPI: 1427582832
Provider Name (Legal Business Name): IJEOMA OGBONNIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11900 AVALON BLVD # 100
LOS ANGELES CA
90061-2866
US

IV. Provider business mailing address

13400 DOTY AVE # 13
HAWTHORNE CA
90250-6241
US

V. Phone/Fax

Practice location:
  • Phone: 310-679-1947
  • Fax:
Mailing address:
  • Phone: 310-679-1947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95005390
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: