Provider Demographics
NPI:1225922974
Name:PROSISE, SHANTITA
Entity type:Individual
Prefix:MRS
First Name:SHANTITA
Middle Name:
Last Name:PROSISE
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 1:7803 MILL RIVER CT
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-9238
Mailing Address - Country:US
Mailing Address - Phone:804-937-0651
Mailing Address - Fax:
Practice Address - Street 1:3906 BEULAH RD
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23237-1456
Practice Address - Country:US
Practice Address - Phone:804-937-0651
Practice Address - Fax:804-937-0651
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-06
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA12001-08-011251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health