Provider Demographics
NPI:1548449572
Name:AGBO, OKWII GLORIA (NP)
Entity type:Individual
Prefix:
First Name:OKWII
Middle Name:GLORIA
Last Name:AGBO
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:P.O BOX 881916
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90009
Mailing Address - Country:US
Mailing Address - Phone:323-531-0915
Mailing Address - Fax:323-953-8446
Practice Address - Street 1:1508 FLORENCE AVENUE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90001
Practice Address - Country:US
Practice Address - Phone:323-531-0915
Practice Address - Fax:323-953-8446
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP14622363LF0000X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP14622Medicaid
CAAGBI04310361OtherNCC