Provider Demographics
NPI:1558052159
Name:IFEMAZI, EMMANUEL (PMHNP)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:
Last Name:IFEMAZI
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 W 190TH ST STE 280
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-4305
Mailing Address - Country:US
Mailing Address - Phone:877-515-8113
Mailing Address - Fax:
Practice Address - Street 1:1225 W 190TH ST STE 280
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4305
Practice Address - Country:US
Practice Address - Phone:877-515-8113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-16
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95025107363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health