Provider Demographics
NPI:1750726188
Name:VINES, SHAUGHANASSEE B (CNM)
Entity type:Individual
Prefix:MS
First Name:SHAUGHANASSEE
Middle Name:B
Last Name:VINES
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 PROVIDENCE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-4122
Mailing Address - Country:US
Mailing Address - Phone:757-550-4132
Mailing Address - Fax:
Practice Address - Street 1:5320 PROVIDENCE RD STE 100
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-4122
Practice Address - Country:US
Practice Address - Phone:757-550-4132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-29
Last Update Date:2022-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC003102367A00000X
CA236069367A00000X
VA0024170738367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1487101747Medicaid