Healthcare Provider Details

I. General information

NPI: 1043967284
Provider Name (Legal Business Name): SHADESIA NICHOLSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHADESIA CHRISTOPHER FNP-C

II. Dates (important events)

Enumeration Date: 03/08/2022
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 NEWTOWN RD
VIRGINIA BEACH VA
23462-5620
US

IV. Provider business mailing address

515 NEWTOWN RD
VIRGINIA BEACH VA
23462-5620
US

V. Phone/Fax

Practice location:
  • Phone: 757-499-7526
  • Fax: 804-355-5216
Mailing address:
  • Phone: 757-499-7526
  • Fax: 804-355-5216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024183858
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: