Healthcare Provider Details

I. General information

NPI: 1063149441
Provider Name (Legal Business Name): AMENAGHAWON OKWUEGBE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 17TH ST
OAKLAND CA
94612-4124
US

IV. Provider business mailing address

280 17TH ST
OAKLAND CA
94612-4124
US

V. Phone/Fax

Practice location:
  • Phone: 510-295-9365
  • Fax:
Mailing address:
  • Phone: 510-295-9365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number218504
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: