Provider Demographics
NPI:1790327310
Name:AMBA, EDITH NUNGONG
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:NUNGONG
Last Name:AMBA
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 1:720 WOOD ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-4413
Mailing Address - Country:US
Mailing Address - Phone:707-476-4012
Mailing Address - Fax:
Practice Address - Street 1:720 WOOD ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4413
Practice Address - Country:US
Practice Address - Phone:707-476-4012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA709572163WP0808X
TX314975164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health