Healthcare Provider Details

I. General information

NPI: 1386161594
Provider Name (Legal Business Name): SHERESE LATASHA BUNKLEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3060 GODWIN BLVD
SUFFOLK VA
23434-8274
US

IV. Provider business mailing address

PO BOX 7068
PORTSMOUTH VA
23707-0068
US

V. Phone/Fax

Practice location:
  • Phone: 757-923-9660
  • Fax: 757-923-9665
Mailing address:
  • Phone: 757-483-7113
  • Fax: 757-483-7151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024175206
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: