Provider Demographics
NPI:1316756588
Name:MIKHA, SHANTAL FARIS (RN)
Entity type:Individual
Prefix:
First Name:SHANTAL
Middle Name:FARIS
Last Name:MIKHA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-5514
Mailing Address - Country:US
Mailing Address - Phone:619-583-7134
Mailing Address - Fax:
Practice Address - Street 1:928 BROADWAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-5514
Practice Address - Country:US
Practice Address - Phone:619-977-3716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-02
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95257661390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty