Healthcare Provider Details

I. General information

NPI: 1003453481
Provider Name (Legal Business Name): SHANNA MICHAEL MILLER-NABAS RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 CHILDRENS WAY
SAN DIEGO CA
92123-4223
US

IV. Provider business mailing address

3020 CHILDRENS WAY
SAN DIEGO CA
92123-4223
US

V. Phone/Fax

Practice location:
  • Phone: 858-576-1700
  • Fax:
Mailing address:
  • Phone: 858-576-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-141
License Number StateGU
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86017372
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: