Healthcare Provider Details

I. General information

NPI: 1134545239
Provider Name (Legal Business Name): AMY LANELLE VONDRAN SHAVER AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2014
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 JOHNSTON WILLIS DR STE 100
NORTH CHESTERFIELD VA
23235-4730
US

IV. Provider business mailing address

7202 GLEN FOREST DR STE 200
RICHMOND VA
23226-3780
US

V. Phone/Fax

Practice location:
  • Phone: 804-330-7990
  • Fax: 804-330-2701
Mailing address:
  • Phone: 804-391-4171
  • Fax: 804-200-6229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001225969
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024171588
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number0024171588
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: