Healthcare Provider Details

I. General information

NPI: 1144400771
Provider Name (Legal Business Name): MARY OKIMOTO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2007
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

892 AEROVISTA PL STE 240
SAN LUIS OBISPO CA
93401-8054
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 400
LOS ANGELES CA
90095-5631
US

V. Phone/Fax

Practice location:
  • Phone: 305-395-3277
  • Fax:
Mailing address:
  • Phone: 310-301-8707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number567717
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number17444
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: