Healthcare Provider Details

I. General information

NPI: 1477099430
Provider Name (Legal Business Name): SHIRLEY CONSTANTINO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2017
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 W LABURNUM AVE
RICHMOND VA
23227-4357
US

IV. Provider business mailing address

PO BOX 91734
RICHMOND VA
23291-1734
US

V. Phone/Fax

Practice location:
  • Phone: 804-354-8108
  • Fax: 804-354-8075
Mailing address:
  • Phone: 804-358-6100
  • Fax: 804-342-7619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number0024173587
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: