Provider Demographics
NPI:1619212081
Name:MOLEDINA, SHABNAM MAHMOOD (NP)
Entity Type:Individual
Prefix:
First Name:SHABNAM
Middle Name:MAHMOOD
Last Name:MOLEDINA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26520 CACTUS AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-3927
Mailing Address - Country:US
Mailing Address - Phone:951-486-5764
Mailing Address - Fax:951-486-5749
Practice Address - Street 1:1502 ARROW HWY
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-5318
Practice Address - Country:US
Practice Address - Phone:909-593-4333
Practice Address - Fax:909-593-5588
Is Sole Proprietor?:No
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21922363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner