MEDICARE: IJEOMA IKE FNP-C, MPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC1500X	Community Health Registered Nurse	550728	CA
2	363L00000X	Nurse Practitioner	95006167	CA
3	363LF0000X	Family Nurse Practitioner	95006167	CA
4	363LP2300X	Primary Care Nurse Practitioner	95006167	CA

General Provider Information

NPI Number	:	1275066029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IJEOMA IKE FNP-C, MPH

Provider Business Mailing Address
First Line	:	11900 AVALON BLVD STE 100
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90061-2867
Country	:	US
Telephone Number	:	323-756-1317
Fax Number	:

Provider Business Practice Location Address
First Line	:	11900 AVALON BLVD STE 100
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90061-2867
Country	:	US
Telephone Number	:	323-756-1317
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/08/2017
Last Update Date	:	04/08/2017

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