Provider Demographics
NPI:1992156962
Name:NNACHETAM, FIDELIA ONYEBUCHI
Entity type:Individual
Prefix:MRS
First Name:FIDELIA
Middle Name:ONYEBUCHI
Last Name:NNACHETAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FIDELIA
Other - Middle Name:ONYEBUCHI
Other - Last Name:DIKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:9140 S NOBEL WAY
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90305-1881
Mailing Address - Country:US
Mailing Address - Phone:310-910-8372
Mailing Address - Fax:
Practice Address - Street 1:8611 CRENSHAW BLVD STE 210
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90305-3306
Practice Address - Country:US
Practice Address - Phone:310-910-8372
Practice Address - Fax:310-672-2280
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003898163WG0000X
CA567085363LF0000X
CA567085-363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily