Healthcare Provider Details

I. General information

NPI: 1639655137
Provider Name (Legal Business Name): TAIWO ADENIKE ALLI FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1751 E GARRY AVE
SANTA ANA CA
92705-5814
US

IV. Provider business mailing address

15243 PLANGER LN
FONTANA CA
92336-1023
US

V. Phone/Fax

Practice location:
  • Phone: 877-896-7350
  • Fax:
Mailing address:
  • Phone: 909-200-5772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95007983
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: