Healthcare Provider Details

I. General information

NPI: 1255911418
Provider Name (Legal Business Name): SHAUTAUQUA BLOCKER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8142 SUNLAND BLVD
SUN VALLEY CA
91352-3948
US

IV. Provider business mailing address

6210 N JONES BLVD UNIT 751042
LAS VEGAS NV
89136-8851
US

V. Phone/Fax

Practice location:
  • Phone: 818-582-8832
  • Fax:
Mailing address:
  • Phone: 601-572-9199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number810948
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number95024737
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: