Healthcare Provider Details

I. General information

NPI: 1255996658
Provider Name (Legal Business Name): AGNES KIMA EYONG CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AGNES KIMA EYONG

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 10/27/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8990 GARFIELD ST STE 6
RIVERSIDE CA
92503-3922
US

IV. Provider business mailing address

181 LADY BELL WAY
PERRIS CA
92571-2996
US

V. Phone/Fax

Practice location:
  • Phone: 562-419-5050
  • Fax:
Mailing address:
  • Phone: 562-419-5050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95022015
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number815089
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: