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General NPI Number Information
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NPI Number | 1881004901
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Entity Type | Individual
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Provider Name | SHASTA MITCHELL-HOLSTON FNP-C
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Gender | Female
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Dates
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Enumeration Date | 04/28/2014
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Last Update Date | 09/05/2018
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Provider Practice Location Address
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Address Line | 3636 HIGH ST
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City | PORTSMOUTH
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State | VA
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Zip | 23707
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Country | US
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Telephone | 757-398-2285
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Fax |
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Provider Business Mailing Address
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Address Line | 36550 CHESTER RD 5404
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City | AVON
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State | OH
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Zip | 44011-1091
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Country | US
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Telephone | 216-526-2214
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 0024176097
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License Number State | VA
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