Provider Demographics
NPI:1891070686
Name:ANUGOM, FELISTA
Entity Type:Individual
Prefix:
First Name:FELISTA
Middle Name:
Last Name:ANUGOM
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 1:16660 PARAMOUNT BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-5458
Mailing Address - Country:US
Mailing Address - Phone:866-214-7214
Mailing Address - Fax:866-214-8786
Practice Address - Street 1:16660 PARAMOUNT BLVD STE 208
Practice Address - Street 2:
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723-5458
Practice Address - Country:US
Practice Address - Phone:866-214-7214
Practice Address - Fax:866-214-8786
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19877363LP0808X, 363LP0808X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care