=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972323285
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANY ROTHSTEIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2024
-----------------------------------------------------
Last Update Date | 10/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1401 S GRAND AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90015-3010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-748-2411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5516 HERMITAGE AVE
-----------------------------------------------------
City | VALLEY VILLAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91607-2018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-397-4339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 95028422
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------