Healthcare Provider Details

I. General information

NPI: 1952934739
Provider Name (Legal Business Name): ETHEL NTOM ODIMEGWU FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 CAMINO DEL RIO S STE 300
SAN DIEGO CA
92108-4014
US

IV. Provider business mailing address

15625 MESA VERDE DR
MORENO VALLEY CA
92555-4220
US

V. Phone/Fax

Practice location:
  • Phone: 619-287-9730
  • Fax: 619-287-4516
Mailing address:
  • Phone: 909-565-2622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95013976
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95013976
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: