Healthcare Provider Details

I. General information

NPI: 1750854865
Provider Name (Legal Business Name): SUSANA GUADALUPE JIMENEZ AG-ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2019
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 MACAW LN
SIMI VALLEY CA
93065-3152
US

IV. Provider business mailing address

124 MACAW LN
SIMI VALLEY CA
93065-3152
US

V. Phone/Fax

Practice location:
  • Phone: 805-306-0304
  • Fax: 805-306-0102
Mailing address:
  • Phone: 805-306-0304
  • Fax: 805-306-0102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95010834
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: