Provider Demographics
NPI:1619509536
Name:WUERTHELE, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WUERTHELE
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 1:1730 AMHERST ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1730 AMHERST ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2807
Practice Address - Country:US
Practice Address - Phone:540-773-8169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-08
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110007775363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program