Healthcare Provider Details

I. General information

NPI: 1174282149
Provider Name (Legal Business Name): SHRUTI SHAH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2021
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 ATLANTIC AVE STE 110
LONG BEACH CA
90807-2254
US

IV. Provider business mailing address

27991 CENTER RIDGE RD
WESTLAKE OH
44145-3902
US

V. Phone/Fax

Practice location:
  • Phone: 440-575-0107
  • Fax: 888-826-1516
Mailing address:
  • Phone: 440-575-0107
  • Fax: 888-826-1516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95019071
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: