Provider Demographics
NPI:1417019936
Name:SAMPLE, SHIRLEY JANE (CRNP)
Entity Type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:JANE
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11525 HANNIBAL RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ARM
Mailing Address - State:MD
Mailing Address - Zip Code:21057-9207
Mailing Address - Country:US
Mailing Address - Phone:443-807-1737
Mailing Address - Fax:
Practice Address - Street 1:1300 BELLONA AVE STE B
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-5466
Practice Address - Country:US
Practice Address - Phone:844-606-5105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR080367363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health