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General NPI Number Information
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NPI Number | 1952934739
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Entity Type | Individual
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Provider Name | ETHEL NTOM ODIMEGWU FNP
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Gender | Male
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Dates
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Enumeration Date | 02/19/2020
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Last Update Date | 09/03/2025
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Provider Practice Location Address
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Address Line | 3633 CAMINO DEL RIO S STE 300
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City | SAN DIEGO
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State | CA
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Zip | 92108-4014
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Country | US
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Telephone | 619-287-9730
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Fax | 619-287-4516
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Provider Business Mailing Address
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Address Line | 15625 MESA VERDE DR
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City | MORENO VALLEY
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State | CA
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Zip | 92555-4220
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Country | US
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Telephone | 909-565-2622
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 95013976
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 95013976
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License Number State | CA
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