Healthcare Provider Details

I. General information

NPI: 1518762616
Provider Name (Legal Business Name): SHAWNA MARIE HUCKABY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2025
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 SPRING ST # B
PLACERVILLE CA
95667-4543
US

IV. Provider business mailing address

935 SPRING ST # B
PLACERVILLE CA
95667-4543
US

V. Phone/Fax

Practice location:
  • Phone: 530-621-6213
  • Fax:
Mailing address:
  • Phone: 530-621-6213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number776411
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: