Healthcare Provider Details

I. General information

NPI: 1487392171
Provider Name (Legal Business Name): GARY SHINE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2022
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CHILDRENS LN
NORFOLK VA
23507-1971
US

IV. Provider business mailing address

1661 SPRING HOUSE TRL
VIRGINIA BEACH VA
23455-7005
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-7315
  • Fax:
Mailing address:
  • Phone: 757-282-9621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number0001272766
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: