=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417559907
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EUDORA KRYSTLE, NNEKA OSUALA MSN, RN, PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2020
-----------------------------------------------------
Last Update Date | 05/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 ROSECRANS AVE STE 500
-----------------------------------------------------
City | MANHATTAN BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90266-3771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-404-7813
-----------------------------------------------------
Fax | 626-261-7019
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1555 ORANGE AVE UNIT 903
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92373-1458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-956-5955
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 95016399
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------