Provider Demographics
NPI:1972550309
Name:SHINABERRY, NINA L (MD)
Entity Type:Individual
Prefix:MRS
First Name:NINA
Middle Name:L
Last Name:SHINABERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:NINA
Other - Middle Name:L
Other - Last Name:LIGHT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:1097 FLEDDERJOHN ROAD
Mailing Address - Street 2:STE 3
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314
Mailing Address - Country:US
Mailing Address - Phone:304-345-0880
Mailing Address - Fax:304-345-1112
Practice Address - Street 1:1097 FLEDDERJOHN ROAD
Practice Address - Street 2:STE 3
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314
Practice Address - Country:US
Practice Address - Phone:304-345-0880
Practice Address - Fax:304-345-1112
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV628103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV113713302002OtherMTN STATE BCBS
WV113713302002OtherMTN STATE BCBS