Provider Demographics
NPI:1609656909
Name:ILOGU, ANTHONY
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:ILOGU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2562
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91386-2562
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27125 SIERRA HWY STE 326
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91351-5432
Practice Address - Country:US
Practice Address - Phone:310-310-4091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95026024363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health