Healthcare Provider Details

I. General information

NPI: 1821474958
Provider Name (Legal Business Name): ANNICA M SHUMNY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 16TH ST STE 125
SANTA MONICA CA
90404-1240
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-315-8900
  • Fax: 310-315-8902
Mailing address:
  • Phone: 310-301-8707
  • Fax: 310-301-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164005771
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085006632
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61459
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: