Healthcare Provider Details

I. General information

NPI: 1902377484
Provider Name (Legal Business Name): SHAUNTEL RENEE NELSON MEDICAL ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2018
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 E 52ND ST
LOS ANGELES CA
90011-4513
US

IV. Provider business mailing address

1453 W 85TH ST UNIT B
LOS ANGELES CA
90047-5412
US

V. Phone/Fax

Practice location:
  • Phone: 323-918-2139
  • Fax:
Mailing address:
  • Phone: 951-305-2770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: