Provider Demographics
NPI:1821310913
Name:CROWDER, SHANA BROOKE (NP)
Entity Type:Individual
Prefix:MISS
First Name:SHANA
Middle Name:BROOKE
Last Name:CROWDER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132 NESTLE QUARRY RD
Mailing Address - Street 2:
Mailing Address - City:FALLING WATERS
Mailing Address - State:WV
Mailing Address - Zip Code:25419-4258
Mailing Address - Country:US
Mailing Address - Phone:304-261-7745
Mailing Address - Fax:
Practice Address - Street 1:1503 POTOMAC AVE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-2930
Practice Address - Country:US
Practice Address - Phone:304-261-7745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-17
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF336174363LF0000X
MDR198459363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily