MEDICARE: CHOMYA OO 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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	95020380	CA

General Provider Information

NPI Number	:	1609510130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHOMYA OO PMHNP

Provider Business Mailing Address
First Line	:	954 W FOOTHILL BLVD STE A
Second Line	:
City	:	UPLAND
State	:	CA
Zip	:	91786-3782
Country	:	US
Telephone Number	:	909-946-4222
Fax Number	:	909-946-8243

Provider Business Practice Location Address
First Line	:	41990 COOK ST BLDG F-2002
Second Line	:
City	:	PALM DESERT
State	:	CA
Zip	:	92211-6100
Country	:	US
Telephone Number	:	760-674-7132
Fax Number	:	760-674-7120

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

Provider Enumeration Date	:	04/21/2022
Last Update Date	:	04/21/2022

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