Provider Demographics
NPI:1265995260
Name:EZENWA, WINIFRED C (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:WINIFRED
Middle Name:C
Last Name:EZENWA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16133 S VERMONT AVE UNIT 17
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4986
Mailing Address - Country:US
Mailing Address - Phone:310-953-7004
Mailing Address - Fax:
Practice Address - Street 1:11938 PARAMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242-2306
Practice Address - Country:US
Practice Address - Phone:562-923-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF11180567363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily