Provider Demographics
NPI:1063181626
Name:QUEEN, SHAWNTE SHANAE (LPN)
Entity type:Individual
Prefix:MISS
First Name:SHAWNTE
Middle Name:SHANAE
Last Name:QUEEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:SHAWNTE
Other - Middle Name:SHANAE
Other - Last Name:QUEEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:550 NORTH CRAIN HWY
Mailing Address - Street 2:SUITE 8:9
Mailing Address - City:GLENBURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061
Mailing Address - Country:US
Mailing Address - Phone:443-517-6552
Mailing Address - Fax:410-946-1752
Practice Address - Street 1:550 NORTH CRAIN HWY
Practice Address - Street 2:SUITE 8:9
Practice Address - City:GLENBURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061
Practice Address - Country:US
Practice Address - Phone:443-517-6552
Practice Address - Fax:410-946-1752
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP54037164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLP54037OtherSTATE LIC