Provider Demographics
NPI:1891145033
Name:ISHAM, LONI
Entity Type:Individual
Prefix:MRS
First Name:LONI
Middle Name:
Last Name:ISHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 RUSTIC CT
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:CA
Mailing Address - Zip Code:95366-9507
Mailing Address - Country:US
Mailing Address - Phone:209-612-8609
Mailing Address - Fax:
Practice Address - Street 1:511 RUSTIC CT
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:CA
Practice Address - Zip Code:95366-9507
Practice Address - Country:US
Practice Address - Phone:209-612-8609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-19
Last Update Date:2016-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38233167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician