Provider Demographics
NPI:1952934739
Name:ODIMEGWU, ETHEL NTOM (FNP)
Entity Type:Individual
Prefix:
First Name:ETHEL
Middle Name:NTOM
Last Name:ODIMEGWU
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15625 MESA VERDE DR
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-4220
Mailing Address - Country:US
Mailing Address - Phone:909-565-2622
Mailing Address - Fax:
Practice Address - Street 1:422 N SAN JACINTO ST
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-3124
Practice Address - Country:US
Practice Address - Phone:909-565-2622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013976363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily