Healthcare Provider Details

I. General information

NPI: 1487408092
Provider Name (Legal Business Name): KAITLYN JEAN SHUMATE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2024
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 SILAS CREEK PKWY
WINSTON SALEM NC
27103-3013
US

IV. Provider business mailing address

PO BOX 100278
GAINESVILLE FL
32610-0278
US

V. Phone/Fax

Practice location:
  • Phone: 336-718-5570
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN11046109
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: