Healthcare Provider Details

I. General information

NPI: 1639583545
Provider Name (Legal Business Name): LISA K IIJIMA N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 BROOKWOOD RD STE 201
ORINDA CA
94563-3047
US

IV. Provider business mailing address

1450 TREAT BLVD STE 300
WALNUT CREEK CA
94597-2168
US

V. Phone/Fax

Practice location:
  • Phone: 925-254-9090
  • Fax:
Mailing address:
  • Phone: 925-952-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number767559
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21058
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: