1609251362 NPI number — SHANITHA NIMALI GUNAWARDENA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609251362 NPI number — SHANITHA NIMALI GUNAWARDENA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUNAWARDENA
Provider First Name:
SHANITHA
Provider Middle Name:
NIMALI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GUNAWARDENA
Provider Other First Name:
SHANITHA
Provider Other Middle Name:
NIMALI
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609251362
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10716 LA TUNA CANYON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUN VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91352-2130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-252-5863
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10716 LA TUNA CANYON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUN VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91352-2130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-252-5863
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/23/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2355S0801X , with the licence number:  SPA 3109 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: SPA 3109 . This is a "CALIFORNIA STATE LICENSE NUMBER SLPA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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