Healthcare Provider Details

I. General information

NPI: 1780917021
Provider Name (Legal Business Name): SHOKO OKADO NITTA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2009
Last Update Date: 01/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 BROCKTON AVE STE 319
RIVERSIDE CA
92501-4027
US

IV. Provider business mailing address

4500 BROCKTON AVE STE 319
RIVERSIDE CA
92501-4027
US

V. Phone/Fax

Practice location:
  • Phone: 951-367-0102
  • Fax:
Mailing address:
  • Phone: 951-384-7422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License Number3037
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number18472
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: