Provider Demographics
NPI:1821474958
Name:SHUMNY, ANNICA M (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:ANNICA
Middle Name:M
Last Name:SHUMNY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-8707
Mailing Address - Fax:310-301-8751
Practice Address - Street 1:1245 16TH ST STE 125
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1240
Practice Address - Country:US
Practice Address - Phone:310-315-8900
Practice Address - Fax:310-315-8902
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005771133V00000X
IL085006632363A00000X
CAPA61459363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered