Healthcare Provider Details

I. General information

NPI: 1639307895
Provider Name (Legal Business Name): SHANICKA N SCARBROUGH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANICKA N WILLIAMS MD

II. Dates (important events)

Enumeration Date: 06/26/2009
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3746 FOOTHILL BLVD # B140
GLENDALE CA
91214-1740
US

IV. Provider business mailing address

PO BOX 221788
SACRAMENTO CA
95822-8788
US

V. Phone/Fax

Practice location:
  • Phone: 310-445-5999
  • Fax: 323-544-4248
Mailing address:
  • Phone: 312-722-2683
  • Fax: 312-275-7549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA144347
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA144347
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: