Provider Demographics
NPI:1720599558
Name:HOWARD, DEIDRA DEHAVEN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:DEHAVEN
Last Name:HOWARD
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9350 WILSHIRE BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-3204
Mailing Address - Country:US
Mailing Address - Phone:323-410-3033
Mailing Address - Fax:323-317-2125
Practice Address - Street 1:123 VISION PARK BLVD
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77384-3001
Practice Address - Country:US
Practice Address - Phone:713-482-3301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-19
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95007754363LF0000X, 363LP2300X
TX1020379363LP2300X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care