Healthcare Provider Details

I. General information

NPI: 1457192841
Provider Name (Legal Business Name): SHADY FAGHIH REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2024
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S VERMONT AVE FL 17
LOS ANGELES CA
90020-1912
US

IV. Provider business mailing address

467 E 44TH CIR
LONG BEACH CA
90807-1403
US

V. Phone/Fax

Practice location:
  • Phone: 213-943-9063
  • Fax:
Mailing address:
  • Phone: 949-929-1986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95026664
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number95026664
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: