Provider Demographics
NPI:1457884793
Name:EZENWA, NKOLI
Entity Type:Individual
Prefix:DR
First Name:NKOLI
Middle Name:
Last Name:EZENWA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NKOLI
Other - Middle Name:
Other - Last Name:NKWOJI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17467 HONEY MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91387-6870
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10626 BALBOA BLVD
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-6329
Practice Address - Country:US
Practice Address - Phone:818-368-2802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006377363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care