Basic Information
| Provider Information | |||||||||
| NPI: | 1750854865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JIMENEZ | ||||||||
| FirstName: | SUSANA | ||||||||
| MiddleName: | GUADALUPE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | AG-ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 STONEBROOK ST | ||||||||
| Address2: | |||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930655368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188260008 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1601 N SEPULVEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | MANHATTAN BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902665111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106583775 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2019 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 95010834 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.