Healthcare Provider Details

I. General information

NPI: 1104328384
Provider Name (Legal Business Name): SHAHLA ALDAVOODI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2018
Last Update Date: 06/29/2022
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18300 ROSCOE BLVD
NORTHRIDGE CA
91325-4105
US

IV. Provider business mailing address

19412 CANTARA ST
RESEDA CA
91335-1007
US

V. Phone/Fax

Practice location:
  • Phone: 818-885-8500
  • Fax:
Mailing address:
  • Phone: 818-749-9087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95015696
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95015696
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: