Provider Demographics
NPI:1629278379
Name:RODRIGUEZ, SHANDREA (FNP)
Entity Type:Individual
Prefix:
First Name:SHANDREA
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 WAYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4304
Mailing Address - Country:US
Mailing Address - Phone:401-521-1221
Mailing Address - Fax:401-454-4189
Practice Address - Street 1:WAYLAND MEDICAL ASSOCIATES
Practice Address - Street 2:160 WAYLAND AVE
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906
Practice Address - Country:US
Practice Address - Phone:401-521-1221
Practice Address - Fax:401-454-4189
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN42313163W00000X
RIAPRN01603363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
RISR67488Medicaid