Provider Demographics
NPI:1710587712
Name:CRISOSTOMO, SHIELA KAYE CHUA
Entity Type:Individual
Prefix:
First Name:SHIELA KAYE
Middle Name:CHUA
Last Name:CRISOSTOMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3916 GOSNOLD AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23508-2916
Mailing Address - Country:US
Mailing Address - Phone:813-992-8029
Mailing Address - Fax:
Practice Address - Street 1:3916 GOSNOLD AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23508-2916
Practice Address - Country:US
Practice Address - Phone:813-992-8029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180700367500000X
390200000X
GUNP0253367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program