MEDICARE: DESIREE JIMMY RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WG0000X	General Practice Registered Nurse	95396299	CA

General Provider Information

NPI Number	:	1104578566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESIREE JIMMY RN

Provider Business Mailing Address
First Line	:	15101 FAIRFIELD RANCH RD
Second Line	:
City	:	CHINO HILLS
State	:	CA
Zip	:	91709
Country	:	US
Telephone Number	:	323-559-6961
Fax Number	:

Provider Business Practice Location Address
First Line	:	1174 MONTECITO DR
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90031-1637
Country	:	US
Telephone Number	:	323-559-6961
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2022
Last Update Date	:	03/26/2025

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