Healthcare Provider Details

I. General information

NPI: 1043653546
Provider Name (Legal Business Name): RENEE SHANTEL JONES RN, BSN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2013
Last Update Date: 04/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 BUSINESS PARK DR SUITE 104
VIRGINIA BEACH VA
23462-6535
US

IV. Provider business mailing address

149 RICHARD SHAW RD
MOYOCK NC
27958-8625
US

V. Phone/Fax

Practice location:
  • Phone: 757-422-5502
  • Fax: 757-455-8055
Mailing address:
  • Phone: 252-435-6055
  • Fax: 757-455-8055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number210378
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number10926412
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: