=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689364911
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN IWUANYANWU
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2023
-----------------------------------------------------
Last Update Date | 05/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11401 BLOOMFIELD AVE
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90650-2015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-688-0550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 507
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90714-0507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-688-0550
-----------------------------------------------------
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 | 95025108
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------