Provider Demographics
NPI:1881782209
Name:YAMAMOTO, SUSAN KAORU (RN)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:KAORU
Last Name:YAMAMOTO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:SUSAN
Other - Middle Name:KAORU
Other - Last Name:BABA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:200 N ELECTRIC AVE
Mailing Address - Street 2:1
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801
Mailing Address - Country:US
Mailing Address - Phone:626-281-1549
Mailing Address - Fax:
Practice Address - Street 1:311 E WINSTON STREET
Practice Address - Street 2:LA MISSION COMMUNITY CLINIC
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013
Practice Address - Country:US
Practice Address - Phone:213-893-1960
Practice Address - Fax:213-893-1962
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA276172163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM70948FMedicaid
CAEAP70948FOtherEAPC
CAEAP70948FOtherEAPC