Healthcare Provider Details

I. General information

NPI: 1740106970
Provider Name (Legal Business Name): ODION TAIYE ODIAGAH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7826 MARBIL LN
RIVERSIDE CA
92504-2695
US

IV. Provider business mailing address

12597 NAPLES WAY
RANCHO CUCAMONGA CA
91739-2631
US

V. Phone/Fax

Practice location:
  • Phone: 909-539-8816
  • Fax:
Mailing address:
  • Phone: 909-539-8816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95025447
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: