Provider Demographics
NPI:1275151359
Name:UPCHURCH, SHAVONNAH
Entity Type:Individual
Prefix:
First Name:SHAVONNAH
Middle Name:
Last Name:UPCHURCH
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:PO BOX 952
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20156-0952
Mailing Address - Country:US
Mailing Address - Phone:678-468-7009
Mailing Address - Fax:
Practice Address - Street 1:1320 CENTRAL PARK BLVD STE 200
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4953
Practice Address - Country:US
Practice Address - Phone:571-662-1062
Practice Address - Fax:571-290-2944
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001225072163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty