Provider Demographics
NPI:1619639333
Name:SHUMBULO, EDEN D (NP)
Entity Type:Individual
Prefix:
First Name:EDEN
Middle Name:D
Last Name:SHUMBULO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5465 N MORGAN ST APT 501
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22312-3328
Mailing Address - Country:US
Mailing Address - Phone:703-283-3923
Mailing Address - Fax:
Practice Address - Street 1:5465 N MORGAN ST APT 501
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22312-3328
Practice Address - Country:US
Practice Address - Phone:703-283-3923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2021084066363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
2021084066OtherANCC