Provider Demographics
NPI:1710544242
Name:OLUKAIKPE OGOM, KELECHI UGONNA
Entity Type:Individual
Prefix:
First Name:KELECHI
Middle Name:UGONNA
Last Name:OLUKAIKPE OGOM
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 1:1809 W REDLANDS BLVD
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8054
Mailing Address - Country:US
Mailing Address - Phone:909-335-3026
Mailing Address - Fax:
Practice Address - Street 1:1809 W REDLANDS BLVD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-8054
Practice Address - Country:US
Practice Address - Phone:909-335-3026
Practice Address - Fax:909-335-3167
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95009577363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health