Provider Demographics
NPI:1780864207
Name:STRUCK, SHIRLEY MAE (LPN)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:MAE
Last Name:STRUCK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 WOODBURN RD
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-1202
Mailing Address - Country:US
Mailing Address - Phone:703-207-7713
Mailing Address - Fax:703-289-2764
Practice Address - Street 1:3340 WOODBURN RD
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-1202
Practice Address - Country:US
Practice Address - Phone:703-207-7713
Practice Address - Fax:703-289-2764
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002075401164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse