Provider Demographics
NPI:1386123206
Name:SHIVAMBO, RACHEL (RN)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:SHIVAMBO
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 1:1818 MICHIGAN AVE APT 303
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-2456
Mailing Address - Country:US
Mailing Address - Phone:210-440-9146
Mailing Address - Fax:
Practice Address - Street 1:1818 MICHIGAN AVE APT 303
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-2456
Practice Address - Country:US
Practice Address - Phone:210-440-9146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-10
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95371861163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173913801Medicaid