Healthcare Provider Details

I. General information

NPI: 1972126472
Provider Name (Legal Business Name): ELAINE KOOIMA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2020
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12519 CAMARERO CT
SAN DIEGO CA
92130-2279
US

IV. Provider business mailing address

12519 CAMARERO CT
SAN DIEGO CA
92130-2279
US

V. Phone/Fax

Practice location:
  • Phone: 858-829-7007
  • Fax:
Mailing address:
  • Phone: 858-829-7007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number479518
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: