Provider Demographics
NPI:1790555654
Name:DRAKE, SHAVON (CRNP)
Entity Type:Individual
Prefix:
First Name:SHAVON
Middle Name:
Last Name:DRAKE
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 1:1936 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002-1219
Mailing Address - Country:US
Mailing Address - Phone:267-972-7293
Mailing Address - Fax:
Practice Address - Street 1:1936 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-1219
Practice Address - Country:US
Practice Address - Phone:267-972-7293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAG10230100363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner