Healthcare Provider Details

I. General information

NPI: 1437233467
Provider Name (Legal Business Name): JAN SHODA RN, PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W 17TH ST
SANTA ANA CA
92706-2316
US

IV. Provider business mailing address

1725 W 17TH ST
SANTA ANA CA
92706-2316
US

V. Phone/Fax

Practice location:
  • Phone: 714-834-8485
  • Fax:
Mailing address:
  • Phone: 714-834-8485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number301667
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: