Basic Information
| Provider Information | |||||||||
| NPI: | 1003279118 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EZEOKOYE | ||||||||
| FirstName: | CALISTA | ||||||||
| MiddleName: | E | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | WHALEM | ||||||||
| OtherFirstName: | CALISTA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1000 SAN GABRIEL BLVD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | ROSEMEAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917704394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237240019 | ||||||||
| FaxNumber: | 3232487044 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 WILSHIRE BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900171931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134817464 | ||||||||
| FaxNumber: | 2134817147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2016 | ||||||||
| LastUpdateDate: | 02/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 95003322 | CA | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 363LF0000X | 95003322 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | 95003322 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.