Provider Demographics
NPI:1386063907
Name:ROEN-PADILLA, SHANASSA NICOLE
Entity type:Individual
Prefix:
First Name:SHANASSA
Middle Name:NICOLE
Last Name:ROEN-PADILLA
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 1:5353 BALBOA BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-2858
Mailing Address - Country:US
Mailing Address - Phone:818-789-7181
Mailing Address - Fax:
Practice Address - Street 1:5353 BALBOA BLVD STE 104
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-2858
Practice Address - Country:US
Practice Address - Phone:818-789-7181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-10
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY290447208000000X
CAA159227208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics