Healthcare Provider Details

I. General information

NPI: 1497648422
Provider Name (Legal Business Name): CHARMAINE NI
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2025
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 W 6TH ST
SAN PEDRO CA
90731-2521
US

IV. Provider business mailing address

805 BERKENSTOCK CIR
PLACENTIA CA
92870-2747
US

V. Phone/Fax

Practice location:
  • Phone: 310-547-0202
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95032021
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: