Provider Demographics
NPI:1619406063
Name:ANUGWOM, CHINENYENWA SOFIA
Entity Type:Individual
Prefix:
First Name:CHINENYENWA
Middle Name:SOFIA
Last Name:ANUGWOM
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:PO BOX 737
Mailing Address - Street 2:
Mailing Address - City:SAN JOAQUIN
Mailing Address - State:CA
Mailing Address - Zip Code:93660-0737
Mailing Address - Country:US
Mailing Address - Phone:559-203-6640
Mailing Address - Fax:
Practice Address - Street 1:4711 W. ASHLAN AVE
Practice Address - Street 2:
Practice Address - City:SAN JOAQUIN
Practice Address - State:CA
Practice Address - Zip Code:93660
Practice Address - Country:US
Practice Address - Phone:559-203-6640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA165415207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine