Provider Demographics
NPI:1780108878
Name:NDIKWA, DEVINE
Entity type:Individual
Prefix:
First Name:DEVINE
Middle Name:
Last Name:NDIKWA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9440 ROSE ST
Mailing Address - Street 2:
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90706-6529
Mailing Address - Country:US
Mailing Address - Phone:310-995-5620
Mailing Address - Fax:
Practice Address - Street 1:3111 LOS FELIZ BLVD STE 211
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90039-1585
Practice Address - Country:US
Practice Address - Phone:866-227-3310
Practice Address - Fax:866-491-1305
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005666363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily