Healthcare Provider Details

I. General information

NPI: 1649922758
Provider Name (Legal Business Name): JUSTINA TENGUH AWAZI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2022
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 ALHAMBRA AVE
MARTINEZ CA
94553-3156
US

IV. Provider business mailing address

2500 ALHAMBRA AVE
MARTINEZ CA
94553-3156
US

V. Phone/Fax

Practice location:
  • Phone: 510-566-4872
  • Fax:
Mailing address:
  • Phone: 510-566-4872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number764451
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95023626
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: