Provider Demographics
NPI:1770512154
Name:SHAGENA, KATHLEEN (CRNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:SHAGENA
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 1:1800 ORLEANS ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287-4563
Mailing Address - Country:US
Mailing Address - Phone:410-955-7935
Mailing Address - Fax:410-614-9983
Practice Address - Street 1:1800 ORLEANS ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-4563
Practice Address - Country:US
Practice Address - Phone:410-955-7935
Practice Address - Fax:410-614-9983
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR093145363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD536270900Medicaid
MD536270900Medicaid
MD536270900Medicaid