Healthcare Provider Details

I. General information

NPI: 1639753262
Provider Name (Legal Business Name): SHAULA CARBAJAL KAUFMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 CAMINO DEL RIO S STE 102
SAN DIEGO CA
92108-3819
US

IV. Provider business mailing address

2810 CAMINO DEL RIO S STE 102
SAN DIEGO CA
92108-3819
US

V. Phone/Fax

Practice location:
  • Phone: 619-299-1419
  • Fax: 858-461-6008
Mailing address:
  • Phone: 619-299-1419
  • Fax: 858-461-6008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95017261
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: