Healthcare Provider Details

I. General information

NPI: 1679110464
Provider Name (Legal Business Name): ANGIE SHAMMO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2019
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E 2ND AVE
ESCONDIDO CA
92025-4212
US

IV. Provider business mailing address

225 E 2ND AVE
ESCONDIDO CA
92025-4212
US

V. Phone/Fax

Practice location:
  • Phone: 760-291-6777
  • Fax: 760-737-7324
Mailing address:
  • Phone: 760-291-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704328368
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95018797
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: