Healthcare Provider Details

I. General information

NPI: 1821827106
Provider Name (Legal Business Name): GEORGINA O IKPEA MSC,APRN,PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2024
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 JACKIE RD SE STE 104
RIO RANCHO NM
87124-1519
US

IV. Provider business mailing address

9050 CARRON DR APT 174
PICO RIVERA CA
90660-3536
US

V. Phone/Fax

Practice location:
  • Phone: 505-515-3982
  • Fax:
Mailing address:
  • Phone: 657-281-8345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number78421
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: