Provider Demographics
NPI:1568727600
Name:GREVEN, SHANA ALEXANDRA (DO)
Entity Type:Individual
Prefix:DR
First Name:SHANA
Middle Name:ALEXANDRA
Last Name:GREVEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2321 WARDS RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-2101
Mailing Address - Country:US
Mailing Address - Phone:434-582-2273
Mailing Address - Fax:
Practice Address - Street 1:2321 WARDS RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-2101
Practice Address - Country:US
Practice Address - Phone:434-582-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-04
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012022304207Q00000X
IL921204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2012022304OtherMISSOURI LICENSE NUMBER
VA0102205830OtherVIRGINIA LICENSE NUMBER