Provider Demographics
NPI:1386014462
Name:ASBERRY, SHAWNTAE (LPN)
Entity Type:Individual
Prefix:
First Name:SHAWNTAE
Middle Name:
Last Name:ASBERRY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LONG WHARF DR
Mailing Address - Street 2:SUITE 321
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5991
Mailing Address - Country:US
Mailing Address - Phone:203-781-4600
Mailing Address - Fax:203-781-4624
Practice Address - Street 1:425 GRANT ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-3222
Practice Address - Country:US
Practice Address - Phone:203-781-4600
Practice Address - Fax:203-781-4624
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT36054164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008023170Medicaid
CT008042339Medicaid
CT008024427Medicaid