Healthcare Provider Details

I. General information

NPI: 1609706266
Provider Name (Legal Business Name): SHAKIBA PEYROVI FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23672 BIRTCHER DR
LAKE FOREST CA
92630-1711
US

IV. Provider business mailing address

1539 CARIBBEAN WAY
LAGUNA BEACH CA
92651-1907
US

V. Phone/Fax

Practice location:
  • Phone: 949-770-7301
  • Fax:
Mailing address:
  • Phone: 949-400-7535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95039669
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: