Basic Information
| Provider Information | |||||||||
| NPI: | 1477753721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JIMENEZ | ||||||||
| FirstName: | IMELDA | ||||||||
| MiddleName: | MEDINA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1433 W MERCED AVE | ||||||||
| Address2: | 103 | ||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917903402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263378000 | ||||||||
| FaxNumber: | 6263371145 | ||||||||
| Practice Location | |||||||||
| Address1: | 1433 W MERCED AVE | ||||||||
| Address2: | 103 | ||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917903402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263378000 | ||||||||
| FaxNumber: | 6263371145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2007 | ||||||||
| LastUpdateDate: | 07/24/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 416351 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 416351 | 01 | CA | NP LICENSE | OTHER |