Provider Demographics
NPI:1124600044
Name:SHAMOON, KERSTEEN S (CM)
Entity Type:Individual
Prefix:
First Name:KERSTEEN
Middle Name:S
Last Name:SHAMOON
Suffix:
Gender:F
Credentials:CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 PRECISION PARK LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-1345
Mailing Address - Country:US
Mailing Address - Phone:619-662-4100
Mailing Address - Fax:
Practice Address - Street 1:875 EL CAJON BLVD
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-5714
Practice Address - Country:US
Practice Address - Phone:619-662-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator