Healthcare Provider Details

I. General information

NPI: 1134079809
Provider Name (Legal Business Name): SANDRA BLAIR EKIMOTO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 W CIVIC CENTER DR STE 200
SANTA ANA CA
92703-2383
US

IV. Provider business mailing address

901 W CIVIC CENTER DR STE 200
SANTA ANA CA
92703-2383
US

V. Phone/Fax

Practice location:
  • Phone: 877-515-8113
  • Fax: 877-538-2102
Mailing address:
  • Phone: 877-515-8113
  • Fax: 877-538-2102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number332703
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95038383
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: