Provider Demographics
NPI:1306861778
Name:LARGE, SHAUNA M (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SHAUNA
Middle Name:M
Last Name:LARGE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:16000 JOHNSTON MEMORIAL DR
Mailing Address - Street 2:SUITE 304
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24211-7664
Mailing Address - Country:US
Mailing Address - Phone:276-258-3600
Mailing Address - Fax:276-258-3605
Practice Address - Street 1:16000 JOHNSTON MEMORIAL DR
Practice Address - Street 2:SUITE 304
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7664
Practice Address - Country:US
Practice Address - Phone:276-258-3600
Practice Address - Fax:276-258-3605
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024165989363LF0000X
TN8397363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4319883OtherBCBS TENNESSEE
VA1306861778Medicaid
TN1526528Medicaid
VAVV9610AMedicare PIN
VA1306861778Medicaid