Provider Demographics
NPI:1992986731
Name:ADEAGBO, GRACE O
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:O
Last Name:ADEAGBO
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 1:9628 ADOREE ST
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90242-4900
Mailing Address - Country:US
Mailing Address - Phone:562-803-7800
Mailing Address - Fax:
Practice Address - Street 1:2204 TORRANCE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-0502
Practice Address - Country:US
Practice Address - Phone:424-488-2030
Practice Address - Fax:424-488-2202
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA635727163W00000X, 163WH0200X
CA95005218363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily