Provider Demographics
NPI:1972973725
Name:OUTLAW, STASHA
Entity Type:Individual
Prefix:
First Name:STASHA
Middle Name:
Last Name:OUTLAW
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 1:15350 NORDHOFF ST STE A
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-2234
Mailing Address - Country:US
Mailing Address - Phone:818-672-8228
Mailing Address - Fax:
Practice Address - Street 1:15350 NORDHOFF ST STE A
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-2234
Practice Address - Country:US
Practice Address - Phone:818-672-8228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84465126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA126800000OtherDENTAL ASSISTANT