Provider Demographics
NPI:1932142544
Name:MIMURA, KEIKO LILLY (MSN, APRN, BC)
Entity Type:Individual
Prefix:
First Name:KEIKO
Middle Name:LILLY
Last Name:MIMURA
Suffix:
Gender:F
Credentials:MSN, APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11500 NIMITZ AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-3566
Mailing Address - Country:US
Mailing Address - Phone:424-832-8368
Mailing Address - Fax:424-832-8270
Practice Address - Street 1:11500 NIMITZ AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-3566
Practice Address - Country:US
Practice Address - Phone:424-832-8368
Practice Address - Fax:424-832-8270
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14487363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology