Provider Demographics
NPI:1588282974
Name:ANSARI, SHAISTA
Entity type:Individual
Prefix:
First Name:SHAISTA
Middle Name:
Last Name:ANSARI
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 1:5084 SAGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-5138
Mailing Address - Country:US
Mailing Address - Phone:909-921-9299
Mailing Address - Fax:
Practice Address - Street 1:13816 NATHAN PL
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-5609
Practice Address - Country:US
Practice Address - Phone:951-242-8875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-11
Last Update Date:2020-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA331800166310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility