Provider Demographics
NPI:1841520939
Name:REEVES, KEMI IYABO (RN, MSN, GNP)
Entity type:Individual
Prefix:MRS
First Name:KEMI
Middle Name:IYABO
Last Name:REEVES
Suffix:
Gender:F
Credentials:RN, MSN, GNP
Other - Prefix:MS
Other - First Name:KEMI
Other - Middle Name:IYABO
Other - Last Name:ADEBAMOWO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN, MSN, GNP
Mailing Address - Street 1:20224 SHERMAN WAY
Mailing Address - Street 2:UNIT #54
Mailing Address - City:WINNETKA
Mailing Address - State:CA
Mailing Address - Zip Code:91306-3237
Mailing Address - Country:US
Mailing Address - Phone:504-259-8657
Mailing Address - Fax:
Practice Address - Street 1:4911 VAN NUYS BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1716
Practice Address - Country:US
Practice Address - Phone:504-259-8657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-12
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19436363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1841520939Medicaid
CADD266YMedicare PIN