Provider Demographics
NPI:1174282149
Name:SHAH, SHRUTI (FNP)
Entity type:Individual
Prefix:
First Name:SHRUTI
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:27991 CENTER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-3902
Mailing Address - Country:US
Mailing Address - Phone:440-575-0107
Mailing Address - Fax:888-826-1516
Practice Address - Street 1:4401 ATLANTIC AVE STE 110
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-2254
Practice Address - Country:US
Practice Address - Phone:440-575-0107
Practice Address - Fax:888-826-1516
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-16
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA95019071363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily