MEDICARE: MS. BRIDGET EHIEMENONYE

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	163WP0808X	Psychiatric/Mental Health Registered Nurse	610189	CA

General Provider Information

NPI Number	:	1962077594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BRIDGET EHIEMENONYE

Provider Business Mailing Address
First Line	:	1600 W AVENUE J
Second Line	:
City	:	LANCASTER
State	:	CA
Zip	:	93534-2894
Country	:	US
Telephone Number	:	661-949-5250
Fax Number	:

Provider Business Practice Location Address
First Line	:	1734 IMPERIAL ST
Second Line	:
City	:	LANCASTER
State	:	CA
Zip	:	93534-2867
Country	:	US
Telephone Number	:	661-755-9824
Fax Number	:

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

Provider Enumeration Date	:	05/25/2021
Last Update Date	:	05/25/2021

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