Provider Demographics
NPI:1013334994
Name:CHITTENDEN, SHANE (DO)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:CHITTENDEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25359 KINSALE PL
Mailing Address - Street 2:
Mailing Address - City:ALDIE
Mailing Address - State:VA
Mailing Address - Zip Code:20105-3066
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25359 KINSALE PL
Practice Address - Street 2:
Practice Address - City:ALDIE
Practice Address - State:VA
Practice Address - Zip Code:20105-3066
Practice Address - Country:US
Practice Address - Phone:571-228-9881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102202034111NX0800X
CA20A12674207ZF0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
No207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology