Provider Demographics
NPI:1881342301
Name:AGYEPONG, ROSEMARY OWUSU
Entity type:Individual
Prefix:
First Name:ROSEMARY
Middle Name:OWUSU
Last Name:AGYEPONG
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 1:13103 QUARTER HORSE DR
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:92880-3910
Mailing Address - Country:US
Mailing Address - Phone:909-455-4663
Mailing Address - Fax:
Practice Address - Street 1:3125 MYERS ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-5527
Practice Address - Country:US
Practice Address - Phone:951-358-7923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95019550363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health