Healthcare Provider Details

I. General information

NPI: 1952814204
Provider Name (Legal Business Name): SHAWNEE LAKAI THOMAS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2017
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11315 PEMBROOKE SQ STE 111
WALDORF MD
20603
US

IV. Provider business mailing address

1068 DORSET DR
WALDORF MD
20602-1909
US

V. Phone/Fax

Practice location:
  • Phone: 240-252-2150
  • Fax: 240-252-2150
Mailing address:
  • Phone: 301-932-9065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR181123
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR181123
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: