Provider Demographics
NPI:1497148688
Name:UTEBOR, ISIOMA
Entity Type:Individual
Prefix:
First Name:ISIOMA
Middle Name:
Last Name:UTEBOR
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 1:900 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRAWLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92227-2630
Mailing Address - Country:US
Mailing Address - Phone:760-344-6471
Mailing Address - Fax:
Practice Address - Street 1:900 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-2630
Practice Address - Country:US
Practice Address - Phone:760-344-6471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-11
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002237363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner