MEDICARE: SHKURTE DERVISHOLLI FNP-C

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	363L00000X	Nurse Practitioner	F06231526	OH

General Provider Information

NPI Number	:	1790463818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHKURTE DERVISHOLLI FNP-C

Provider Business Mailing Address
First Line	:	4950 CORNERSTONE NORTH BLVD UNIT 1305
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45440-2364
Country	:	US
Telephone Number	:	937-723-1389
Fax Number	:

Provider Business Practice Location Address
First Line	:	4950 CORNERSTONE NORTH BLVD UNIT 1305
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45440-2364
Country	:	US
Telephone Number	:	937-723-1389
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2023
Last Update Date	:	07/10/2023

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