Healthcare Provider Details

I. General information

NPI: 1780304907
Provider Name (Legal Business Name): MS. SHANNON MELODY MIZRAHI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 E 2ND ST
POMONA CA
91766-1854
US

IV. Provider business mailing address

3953 SAPPHIRE DR
ENCINO CA
91436-3639
US

V. Phone/Fax

Practice location:
  • Phone: 909-623-6116
  • Fax:
Mailing address:
  • Phone: 818-634-9787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: