Provider Demographics
NPI:1558980581
Name:NEALLY-SPORTATO, SHAUNA (LVN)
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:
Last Name:NEALLY-SPORTATO
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15259 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-3219
Mailing Address - Country:US
Mailing Address - Phone:805-453-0832
Mailing Address - Fax:
Practice Address - Street 1:15259 MONROE AVE
Practice Address - Street 2:
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-3219
Practice Address - Country:US
Practice Address - Phone:805-453-0832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA273842164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse