Provider Demographics
NPI:1417036195
Name:SOUBRA, KATHERINE KAWAKAMI (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:KAWAKAMI
Last Name:SOUBRA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12122 DIAMOND ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92845-1819
Mailing Address - Country:US
Mailing Address - Phone:714-897-9748
Mailing Address - Fax:
Practice Address - Street 1:2701 ATLANTIC AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2701
Practice Address - Country:US
Practice Address - Phone:562-595-4827
Practice Address - Fax:562-981-6898
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA301288363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA301288OtherNURSE PRACTITIONER