Healthcare Provider Details

I. General information

NPI: 1932142544
Provider Name (Legal Business Name): KEIKO LILLY MIMURA MSN, APRN, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11500 NIMITZ AVE
LOS ANGELES CA
90049-3566
US

IV. Provider business mailing address

11500 NIMITZ AVE
LOS ANGELES CA
90049-3566
US

V. Phone/Fax

Practice location:
  • Phone: 424-832-8368
  • Fax: 424-832-8270
Mailing address:
  • Phone: 424-832-8368
  • Fax: 424-832-8270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number14487
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: