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General NPI Number Information
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NPI Number | 1922713254
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Entity Type | Individual
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Provider Name | SHAVONNE LARCENIA OVERTON
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Gender | Female
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Dates
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Enumeration Date | 01/20/2023
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Last Update Date | 04/17/2025
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Provider Practice Location Address
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Address Line | 158 AMITY RD # 280
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City | NEW HAVEN
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State | CT
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Zip | 06515-1405
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Country | US
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Telephone | 203-404-3463
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Fax | 203-563-9255
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Provider Business Mailing Address
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Address Line | PO BOX 745254
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City | ATLANTA
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State | GA
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Zip | 30374-5254
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Country | US
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Telephone | 773-352-1515
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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 | 12.011424
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License Number State | CT
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