MEDICARE: SHINING STAR PSYCHIATRIC CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1053149211
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHINING STAR PSYCHIATRIC CARE LLC

Provider Business Mailing Address
First Line	:	2807 N PARHAM RD STE 311
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23294-4410
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2807 N PARHAM RD STE 311
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23294-4410
Country	:	US
Telephone Number	:	940-249-0272
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MELITA WILSON PRIMUS
Credential	:
Telephone Number	:	804-470-9371

Provider Enumeration Date	:	07/22/2024
Last Update Date	:	09/02/2025

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