Provider Demographics
NPI:1750063616
Name:HEADLEY, SHAWNECIA (MSN-FNP)
Entity type:Individual
Prefix:MS
First Name:SHAWNECIA
Middle Name:
Last Name:HEADLEY
Suffix:
Gender:F
Credentials:MSN-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 LAWN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4916
Mailing Address - Country:US
Mailing Address - Phone:203-260-3399
Mailing Address - Fax:
Practice Address - Street 1:8 S COMMONS RD
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06704-1035
Practice Address - Country:US
Practice Address - Phone:203-759-1229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12177363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily