=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720538788
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTA SHAMBAUGH PMHNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2016
-----------------------------------------------------
Last Update Date | 10/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4060 FAIRMOUNT AVE
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92105-1608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-280-4213
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4060 FAIRMOUNT AVE
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92105-1608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-280-4213
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 95031769
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Registered Nurse
-----------------------------------------------------
License Number | 95097866
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163WP0809X
-----------------------------------------------------
Taxonomy Name | Adult Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | 95097866
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------