Healthcare Provider Details

I. General information

NPI: 1063990133
Provider Name (Legal Business Name): TINA SHIZUKO KAMI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3356 W BALL RD STE 100
ANAHEIM CA
92804-3727
US

IV. Provider business mailing address

2509 S DEEGAN DR
SANTA ANA CA
92704-5504
US

V. Phone/Fax

Practice location:
  • Phone: 714-827-6625
  • Fax: 714-827-9726
Mailing address:
  • Phone: 714-612-3158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNPF95009496
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: