Provider Demographics
NPI:1740977545
Name:SAMUELS, SHANAE DEANA
Entity type:Individual
Prefix:
First Name:SHANAE
Middle Name:DEANA
Last Name:SAMUELS
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 1:4400 HARLESDEN DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-4651
Mailing Address - Country:US
Mailing Address - Phone:619-254-4172
Mailing Address - Fax:
Practice Address - Street 1:4400 HARLESDEN DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-4651
Practice Address - Country:US
Practice Address - Phone:619-254-4172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver