Provider Demographics
NPI:1578210167
Name:NWAGBUO, DARLENE
Entity Type:Individual
Prefix:
First Name:DARLENE
Middle Name:
Last Name:NWAGBUO
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 1:1000 BROADWAY FL 1
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-7417
Mailing Address - Country:US
Mailing Address - Phone:619-401-5424
Mailing Address - Fax:619-401-5452
Practice Address - Street 1:1000 BROADWAY FL 1
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-7417
Practice Address - Country:US
Practice Address - Phone:619-401-5424
Practice Address - Fax:619-401-5452
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-03
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1079261041C0700X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA171M00000XMedicaid