Healthcare Provider Details

I. General information

NPI: 1134527690
Provider Name (Legal Business Name): SHANNON CHAKEDIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON BROUMAN NP

II. Dates (important events)

Enumeration Date: 12/16/2014
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 LA CASA VIA STE 390
WALNUT CREEK CA
94598-6101
US

IV. Provider business mailing address

1450 TREAT BLVD # 300
WALNUT CREEK CA
94597-2168
US

V. Phone/Fax

Practice location:
  • Phone: 925-692-5610
  • Fax:
Mailing address:
  • Phone: 925-952-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCOA.18791-NP
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number766408
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP95010200
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: