Healthcare Provider Details

I. General information

NPI: 1225520661
Provider Name (Legal Business Name): SHAUNTARA ANN ANGELO CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 ALEXANDER SPRING RD
CARLISLE PA
17015-6940
US

IV. Provider business mailing address

361 ALEXANDER SPRING RD
CARLISLE PA
17015-6940
US

V. Phone/Fax

Practice location:
  • Phone: 717-960-3414
  • Fax:
Mailing address:
  • Phone: 717-960-1687
  • Fax: 717-960-3487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberSP018809
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberSP018809
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierSP018809
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCRNP LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: