Provider Demographics
NPI:1043861016
Name:SHINE, AMBER THERESA
Entity Type:Individual
Prefix:MS
First Name:AMBER
Middle Name:THERESA
Last Name:SHINE
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 1:241 FESTIVAL DR
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92057-5135
Mailing Address - Country:US
Mailing Address - Phone:760-216-2321
Mailing Address - Fax:
Practice Address - Street 1:3822 GARFIELD ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-4031
Practice Address - Country:US
Practice Address - Phone:760-842-4215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-21
Last Update Date:2019-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB5302709OtherDRIVER LICENSE