Healthcare Provider Details

I. General information

NPI: 1164629697
Provider Name (Legal Business Name): GRACE EBENUWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12021 WILMINGTON AVE
LOS ANGELES CA
90059-3019
US

IV. Provider business mailing address

1731 STEARNS DR
LOS ANGELES CA
90035-4627
US

V. Phone/Fax

Practice location:
  • Phone: 310-668-4506
  • Fax: 310-763-8909
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberRN401793
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: