Provider Demographics
NPI:1750958633
Name:HAXTON, SHABANA (RN, NP)
Entity type:Individual
Prefix:
First Name:SHABANA
Middle Name:
Last Name:HAXTON
Suffix:
Gender:F
Credentials:RN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 E ONTARIO AVE # 102-103
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-8671
Mailing Address - Country:US
Mailing Address - Phone:951-496-5238
Mailing Address - Fax:
Practice Address - Street 1:1101 CALIFORNIA AVE STE 100
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-6472
Practice Address - Country:US
Practice Address - Phone:951-496-5238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95018274163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent