Provider Demographics
NPI:1255911418
Name:BLOCKER, SHAUTAUQUA (APRN)
Entity type:Individual
Prefix:
First Name:SHAUTAUQUA
Middle Name:
Last Name:BLOCKER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6210 N JONES BLVD UNIT 751042
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89136-8851
Mailing Address - Country:US
Mailing Address - Phone:601-572-9199
Mailing Address - Fax:
Practice Address - Street 1:8142 SUNLAND BLVD
Practice Address - Street 2:
Practice Address - City:SUN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91352-3948
Practice Address - Country:US
Practice Address - Phone:818-582-8832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV810948363LP0808X
CA95024737364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health