Provider Demographics
NPI:1427582832
Name:OGBONNIA, IJEOMA
Entity Type:Individual
Prefix:
First Name:IJEOMA
Middle Name:
Last Name:OGBONNIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13400 DOTY AVE
Mailing Address - Street 2:# 13
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-6241
Mailing Address - Country:US
Mailing Address - Phone:310-679-1947
Mailing Address - Fax:
Practice Address - Street 1:11900 AVALON BLVD
Practice Address - Street 2:# 100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90061-2866
Practice Address - Country:US
Practice Address - Phone:310-679-1947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005390363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily