Provider Demographics
NPI:1205240017
Name:SHAESTEH, NESYAH
Entity type:Individual
Prefix:
First Name:NESYAH
Middle Name:
Last Name:SHAESTEH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NESYAH
Other - Middle Name:
Other - Last Name:SHAYESTEH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11631 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-3572
Mailing Address - Country:US
Mailing Address - Phone:818-764-8838
Mailing Address - Fax:
Practice Address - Street 1:11631 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3572
Practice Address - Country:US
Practice Address - Phone:818-764-8838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-19
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA51527207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine