Provider Demographics
NPI:1154772135
Name:MCINTOSH, STARISHA
Entity type:Individual
Prefix:
First Name:STARISHA
Middle Name:
Last Name:MCINTOSH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 OLIVER RD # 1164
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-3467
Mailing Address - Country:US
Mailing Address - Phone:510-938-3607
Mailing Address - Fax:
Practice Address - Street 1:1250 OLIVER RD.
Practice Address - Street 2:1164
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534
Practice Address - Country:US
Practice Address - Phone:510-938-3607
Practice Address - Fax:310-945-3356
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95030920363L00000X
CA95255346163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty