Provider Demographics
NPI:1841036761
Name:WASHINGTON, SHANTALE (FNP)
Entity type:Individual
Prefix:
First Name:SHANTALE
Middle Name:
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3422 CROW POINT WAY
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-7063
Mailing Address - Country:US
Mailing Address - Phone:757-402-0435
Mailing Address - Fax:
Practice Address - Street 1:10175 LITTLE PATUXENT PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2655
Practice Address - Country:US
Practice Address - Phone:855-247-8474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-02
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF07240070363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner