Healthcare Provider Details

I. General information

NPI: 1689071169
Provider Name (Legal Business Name): EBELE OYIBO MBELEDOGU DNP,FNP-BC, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2014
Last Update Date: 02/10/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 DOWNEY AVE
MODESTO CA
95354-1208
US

IV. Provider business mailing address

2501 MCHENRY AVE STE F
MODESTO CA
95350-3257
US

V. Phone/Fax

Practice location:
  • Phone: 209-341-1824
  • Fax:
Mailing address:
  • Phone: 812-205-6598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number95001325
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95001325
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95001325
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number95001325
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95024378
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: