NPI |
1902377484 |
The other abbreviations for professional degrees or credentials used or held by the provider,
if the provider is an individual. Examples
are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations
will not be verified by NPS. |
Entity Type Code |
1 |
Code identifying the type of other name. Codes are: 1 = former name; 2 = professional
name; 3 = doing business as (d/b/ a) name; 4 = former legal business name; 5 = other. |
Provider Last Name Legal Name |
NELSON |
The last name of the provider. If the provider is an individual, this is the legal name. |
Provider First Name |
SHAUNTEL |
The first name of the provider, if the provider
is an individual. |
Provider Middle Name |
RENEE |
The State code in the location of the provider
being identified. |
Provider Credential Text |
RAD-T |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Provider First Line Business Practice Location Address |
1481 N. WINDSOR DR. |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address City Name |
SAN BERNARDINO |
The telephone number associated with the location address of the provider being identified. |
Provider Business Practice Location Address State Name |
CA |
The date the provider was assigned a unique identifier (assigned an NPI). |
Provider Business Practice Location Address Postal Code |
92404 |
The date that a record was last updated or changed. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The code designating the provider’s gender if the provider is a person. |
Provider Business Practice Location Address Telephone Number |
9093616470 |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Provider Enumeration Date |
12/10/2018 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Last Update Date |
12/10/2018 |
The date that a record was last updated or changed. |
Provider Gender Code |
F |
The code designating the provider’s gender if the provider is a person. |
Healthcare Provider Taxonomy Code 1 |
390200000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
Is Sole Proprietor |
N |
|