Healthcare Provider Details

I. General information

NPI: 1538886890
Provider Name (Legal Business Name): JAMEL JONATHAN SHAMIYEH RN, MSN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

11301 WILSHIRE BLVD
LOS ANGELES CA
90073-1003
US

V. Phone/Fax

Practice location:
  • Phone: 310-478-3711
  • Fax:
Mailing address:
  • Phone: 310-478-3711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95026128
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95326297
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR240115
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: