Provider Demographics
NPI:1114722774
Name:KIM, CHARLENE NOMURA
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:NOMURA
Last Name:KIM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5270 SILVER ARROW DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-3742
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5270 SILVER ARROW DR
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-3742
Practice Address - Country:US
Practice Address - Phone:310-986-1250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-18
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95028517363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily