Healthcare Provider Details

I. General information

NPI: 1154959138
Provider Name (Legal Business Name): JAIME RENEE REISE NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 03/27/2020
Certification Date: 03/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8358 SANTA MONICA BLVD
WEST HOLLYWOOD CA
90069-4313
US

IV. Provider business mailing address

1316 BARRY AVE APT 2
LOS ANGELES CA
90025-3954
US

V. Phone/Fax

Practice location:
  • Phone: 323-300-6360
  • Fax:
Mailing address:
  • Phone: 314-629-3649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number95008595
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: