Provider Demographics
NPI:1750854865
Name:JIMENEZ, SUSANA GUADALUPE (AG-ACNP)
Entity Type:Individual
Prefix:MRS
First Name:SUSANA
Middle Name:GUADALUPE
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 MACAW LN
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-3152
Mailing Address - Country:US
Mailing Address - Phone:805-306-0304
Mailing Address - Fax:805-306-0102
Practice Address - Street 1:124 MACAW LN
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-3152
Practice Address - Country:US
Practice Address - Phone:805-306-0304
Practice Address - Fax:805-306-0102
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010834363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care