Provider Demographics
NPI:1548042880
Name:MBADUGHA, IJEOMA R (NP)
Entity type:Individual
Prefix:
First Name:IJEOMA
Middle Name:R
Last Name:MBADUGHA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9431 HAVEN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5879
Mailing Address - Country:US
Mailing Address - Phone:909-500-2010
Mailing Address - Fax:800-331-4078
Practice Address - Street 1:9431 HAVEN AVE STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5879
Practice Address - Country:US
Practice Address - Phone:909-500-2010
Practice Address - Fax:800-331-4078
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-20
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027780363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner