Provider Demographics
NPI:1811671910
Name:LI, CARMEN (NP)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:LI
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 1:5536 SULTANA AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPLE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91780-2322
Mailing Address - Country:US
Mailing Address - Phone:626-217-5863
Mailing Address - Fax:
Practice Address - Street 1:2530 SAN VICENTE BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90402-2321
Practice Address - Country:US
Practice Address - Phone:310-310-3776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95022301363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner