Healthcare Provider Details

I. General information

NPI: 1225521735
Provider Name (Legal Business Name): SHANNON ISABEL KURUVILLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2018
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 LEE ST
CHARLOTTESVILLE VA
22908-0816
US

IV. Provider business mailing address

1215 LEE ST BOX 800376
CHARLOTTESVILLE VA
22908-0816
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-5078
  • Fax: 434-924-8118
Mailing address:
  • Phone: 434-924-5078
  • Fax: 434-924-8118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: