Provider Demographics
NPI:1881004901
Name:MITCHELL-HOLSTON, SHASTA (FNP-C)
Entity type:Individual
Prefix:
First Name:SHASTA
Middle Name:
Last Name:MITCHELL-HOLSTON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:SHASTA
Other - Middle Name:
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:36550 CHESTER RD
Mailing Address - Street 2:5404
Mailing Address - City:AVON
Mailing Address - State:OH
Mailing Address - Zip Code:44011-1091
Mailing Address - Country:US
Mailing Address - Phone:216-526-2214
Mailing Address - Fax:
Practice Address - Street 1:3636 HIGH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707
Practice Address - Country:US
Practice Address - Phone:757-398-2285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-28
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024176097363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0127593Medicaid
OH0127593Medicaid
OHDE0340Medicare PIN