Provider Demographics
NPI:1083356869
Name:DESHIELDS, SIMONE
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:
Last Name:DESHIELDS
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 1:2245 JOHN MATICH DR
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-9513
Mailing Address - Country:US
Mailing Address - Phone:909-498-6442
Mailing Address - Fax:
Practice Address - Street 1:1001 POTRERO AVE BLDG 80-83
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:628-206-5252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty