Provider Demographics
NPI:1710984984
Name:SHAND, PHYLLIS CVACH (CRNP)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:CVACH
Last Name:SHAND
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 1:7001 HOLLENBERRY RD
Mailing Address - Street 2:
Mailing Address - City:SYKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21784-7606
Mailing Address - Country:US
Mailing Address - Phone:410-795-7529
Mailing Address - Fax:410-795-2828
Practice Address - Street 1:1645 LIBERTY RD
Practice Address - Street 2:SUITE 204
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-6521
Practice Address - Country:US
Practice Address - Phone:410-795-7737
Practice Address - Fax:410-795-2828
Is Sole Proprietor?:No
Enumeration Date:2005-07-03
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR041230363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD277541700Medicaid
MD23951400Medicaid
MDR12676Medicare UPIN
MD277541700Medicaid