Provider Demographics
NPI:1912689464
Name:NWABA, ALEX
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:NWABA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11313 OXNARD ST APT 313
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-4270
Mailing Address - Country:US
Mailing Address - Phone:310-982-8170
Mailing Address - Fax:
Practice Address - Street 1:679 S NEW HAMPSHIRE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-1355
Practice Address - Country:US
Practice Address - Phone:626-842-7587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker