Provider Demographics
NPI:1548935299
Name:OMANE, KOFI (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:KOFI
Middle Name:
Last Name:OMANE
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5743 CORSA AVE STE 116
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91362-6458
Mailing Address - Country:US
Mailing Address - Phone:805-702-8551
Mailing Address - Fax:
Practice Address - Street 1:5743 CORSA AVE STE 116
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91362-6458
Practice Address - Country:US
Practice Address - Phone:805-702-8551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-14
Last Update Date:2024-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95017886363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health