Healthcare Provider Details

I. General information

NPI: 1104461938
Provider Name (Legal Business Name): SHAZIA TABASUM MALIK NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2019
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 M ST
FRESNO CA
93721-1805
US

IV. Provider business mailing address

5170 N FLOYD AVE
FRESNO CA
93723-9435
US

V. Phone/Fax

Practice location:
  • Phone: 550-600-9300
  • Fax:
Mailing address:
  • Phone: 559-421-5955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95022173
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95022173
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number748392
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: