Provider Demographics
NPI:1922688209
Name:VINES, SHANIQUA L
Entity Type:Individual
Prefix:
First Name:SHANIQUA
Middle Name:L
Last Name:VINES
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 1:3100 LONDON BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-3402
Mailing Address - Country:US
Mailing Address - Phone:757-237-7949
Mailing Address - Fax:
Practice Address - Street 1:3100 LONDON BLVD STE 3
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3402
Practice Address - Country:US
Practice Address - Phone:757-237-7949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide