=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801528997
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAIREE SHAILESHKUMAR DALWADI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2022
-----------------------------------------------------
Last Update Date | 06/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4055 VALLEY VIEW LN
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75244-5074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-856-9448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4055 VALLEY VIEW LN
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75244-5074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-856-9448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 4704326096
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------