Provider Demographics
NPI:1447052618
Name:LIM, NELLY (PA-C)
Entity type:Individual
Prefix:
First Name:NELLY
Middle Name:
Last Name:LIM
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16465 SIERRA LAKES PKWY STE 115
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16465 SIERRA LAKES PKWY STE 115
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1242
Practice Address - Country:US
Practice Address - Phone:909-823-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-26
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA66022363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant