Provider Demographics
NPI:1275066029
Name:IKE, IJEOMA (FNP-C, MPH)
Entity Type:Individual
Prefix:
First Name:IJEOMA
Middle Name:
Last Name:IKE
Suffix:
Gender:F
Credentials:FNP-C, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11900 AVALON BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90061-2867
Mailing Address - Country:US
Mailing Address - Phone:323-756-1317
Mailing Address - Fax:
Practice Address - Street 1:11900 AVALON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90061-2867
Practice Address - Country:US
Practice Address - Phone:323-756-1317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-08
Last Update Date:2017-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550728163WC1500X
CA95006167363L00000X, 363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care