Healthcare Provider Details

I. General information

NPI: 1033003132
Provider Name (Legal Business Name): DEMIANA A SHENOUDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2025
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9570 CENTER AVE
RANCHO CUCAMONGA CA
91730-5842
US

IV. Provider business mailing address

9570 CENTER AVE STE 100
RANCHO CUCAMONGA CA
91730-5842
US

V. Phone/Fax

Practice location:
  • Phone: 909-980-4755
  • Fax:
Mailing address:
  • Phone: 909-980-4755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number140172
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: