Provider Demographics
NPI:1104647205
Name:NAZARI, ROSHANA AMIR
Entity type:Individual
Prefix:
First Name:ROSHANA
Middle Name:AMIR
Last Name:NAZARI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 NEVADA ST SUITE 101
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374
Mailing Address - Country:US
Mailing Address - Phone:714-468-4177
Mailing Address - Fax:
Practice Address - Street 1:1030 NEVADA ST STE 101
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-2957
Practice Address - Country:US
Practice Address - Phone:909-966-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95032224363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health