Provider Demographics
NPI:1003279118
Name:EZEOKOYE, CALISTA E
Entity Type:Individual
Prefix:
First Name:CALISTA
Middle Name:E
Last Name:EZEOKOYE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CALISTA
Other - Middle Name:
Other - Last Name:WHALEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1338 E DENWALL DR STE 200
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-3156
Mailing Address - Country:US
Mailing Address - Phone:323-426-5200
Mailing Address - Fax:323-426-5252
Practice Address - Street 1:2917 W VERNON AVE # B
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-4714
Practice Address - Country:US
Practice Address - Phone:323-426-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003322163WP0808X, 363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily