Provider Demographics
NPI:1891170148
Name:VILLANUEVA, SHERYL
Entity Type:Individual
Prefix:
First Name:SHERYL
Middle Name:
Last Name:VILLANUEVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4103 JEWEL ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22312-1044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4600 MITCHELLVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3110
Practice Address - Country:US
Practice Address - Phone:301-352-3847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0203014673390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program