Provider Demographics
NPI:1649924051
Name:SHIMA, CARISSA A
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:A
Last Name:SHIMA
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 1:912 IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-1109
Mailing Address - Country:US
Mailing Address - Phone:319-404-9475
Mailing Address - Fax:
Practice Address - Street 1:912 IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-1109
Practice Address - Country:US
Practice Address - Phone:319-404-9475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-05
Last Update Date:2022-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11040225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA