Provider Demographics
NPI:1992396931
Name:CHUKWUOCHA, VIVIAN C
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:C
Last Name:CHUKWUOCHA
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 1:12281 KEENLAND DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-9062
Mailing Address - Country:US
Mailing Address - Phone:310-709-6042
Mailing Address - Fax:
Practice Address - Street 1:12281 KEENLAND DR
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-9062
Practice Address - Country:US
Practice Address - Phone:310-709-6042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95016227363LP0808X
CA576694163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health