Healthcare Provider Details

I. General information

NPI: 1972020428
Provider Name (Legal Business Name): SHAWAVIAN A FARMER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2017
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17637 CALLE DE AMIGOS
MORENO VALLEY CA
92551-6351
US

IV. Provider business mailing address

17637 CALLE DE AMIGOS
MORENO VALLEY CA
92551-6351
US

V. Phone/Fax

Practice location:
  • Phone: 951-543-7438
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: