Healthcare Provider Details

I. General information

NPI: 1841941804
Provider Name (Legal Business Name): VICTORIA CHIOMA EZEONYE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2022
Last Update Date: 01/12/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 E 120TH ST
LOS ANGELES CA
90059-3026
US

IV. Provider business mailing address

15716 HARVEST MOON ST
LA PUENTE CA
91744-1634
US

V. Phone/Fax

Practice location:
  • Phone: 424-338-1781
  • Fax:
Mailing address:
  • Phone: 562-686-7319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95019710
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: