Healthcare Provider Details

I. General information

NPI: 1942028477
Provider Name (Legal Business Name): DIANA O UKPONG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 10/02/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1798 N GAREY AVE
POMONA CA
91767-2918
US

IV. Provider business mailing address

482 GREEN ORCHARD PL
RIVERSIDE CA
92506-7590
US

V. Phone/Fax

Practice location:
  • Phone: 951-283-2145
  • Fax:
Mailing address:
  • Phone: 951-283-2145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number520770
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: