Healthcare Provider Details

I. General information

NPI: 1043619547
Provider Name (Legal Business Name): SHAVONNE MARIE GUMBS MSN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. SHAVONNE MARIE SALAAM

II. Dates (important events)

Enumeration Date: 08/20/2014
Last Update Date: 03/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6111 HIGH BRIDGE RD
BOWIE MD
20720-5216
US

IV. Provider business mailing address

4921 COLLINGTONS BOUNTY DR
BOWIE MD
20720-5627
US

V. Phone/Fax

Practice location:
  • Phone: 301-503-1490
  • Fax: 301-576-5197
Mailing address:
  • Phone: 240-645-9037
  • Fax: 240-645-9037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR190102
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: