Provider Demographics
NPI:1407548761
Name:EGIEBOR, OSATOHANMWEN PRINCESS-REBECCA (BS)
Entity Type:Individual
Prefix:
First Name:OSATOHANMWEN
Middle Name:PRINCESS-REBECCA
Last Name:EGIEBOR
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:994 W NORWOOD ST
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92377-8203
Mailing Address - Country:US
Mailing Address - Phone:909-543-5215
Mailing Address - Fax:
Practice Address - Street 1:994 W NORWOOD ST
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92377-8203
Practice Address - Country:US
Practice Address - Phone:909-543-5215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker