Provider Demographics
NPI:1922383892
Name:IM, EUNICE (NP)
Entity Type:Individual
Prefix:
First Name:EUNICE
Middle Name:
Last Name:IM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8110 AIRPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3119
Mailing Address - Country:US
Mailing Address - Phone:310-674-0144
Mailing Address - Fax:310-674-1704
Practice Address - Street 1:8110 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3119
Practice Address - Country:US
Practice Address - Phone:310-674-0144
Practice Address - Fax:310-674-1704
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20789363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20789OtherCA STATE LICENSE