MEDICARE: MRS. KEMI IYABO REEVES RN, MSN, GNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	19436	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841520939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KEMI IYABO REEVES RN, MSN, GNP

Provider Business Mailing Address
First Line	:	20224 SHERMAN WAY
Second Line	:	UNIT #54
City	:	WINNETKA
State	:	CA
Zip	:	91306-3237
Country	:	US
Telephone Number	:	504-259-8657
Fax Number	:

Provider Business Practice Location Address
First Line	:	4911 VAN NUYS BLVD
Second Line	:	SUITE 100
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91403-1716
Country	:	US
Telephone Number	:	504-259-8657
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2010
Last Update Date	:	04/09/2012

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