Basic Information
| Provider Information | |||||||||
| NPI: | 1104328384 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALDAVOODI | ||||||||
| FirstName: | SHAHLA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19412 CANTARA ST | ||||||||
| Address2: | |||||||||
| City: | RESEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913351007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187499087 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18300 ROSCOE BLVD | ||||||||
| Address2: | |||||||||
| City: | NORTHRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913254105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188858500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2018 | ||||||||
| LastUpdateDate: | 06/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95015696 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | 95015696 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.