MEDICARE: QUEEN A IGBONAGWAM PMHNP

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	163W00000X	Registered Nurse	668489	CA
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	95020434	CA

General Provider Information

NPI Number	:	1306526058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	QUEEN A IGBONAGWAM PMHNP

Provider Business Mailing Address
First Line	:	1039 E HELMICK ST
Second Line	:
City	:	CARSON
State	:	CA
Zip	:	90746-3039
Country	:	US
Telephone Number	:	310-293-7764
Fax Number	:	310-632-4984

Provider Business Practice Location Address
First Line	:	1039 E HELMICK ST
Second Line	:
City	:	CARSON
State	:	CA
Zip	:	90746-3039
Country	:	US
Telephone Number	:	310-293-7764
Fax Number	:	310-632-4984

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

Provider Enumeration Date	:	07/18/2023
Last Update Date	:	07/18/2023

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