Provider Demographics
NPI:1063802312
Name:KLINE, SHAUNTELL REED (NP)
Entity type:Individual
Prefix:
First Name:SHAUNTELL
Middle Name:REED
Last Name:KLINE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHAUNTELL
Other - Middle Name:
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2019 TATE SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1131
Mailing Address - Country:US
Mailing Address - Phone:434-846-7374
Mailing Address - Fax:434-846-1910
Practice Address - Street 1:2019 TATE SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1131
Practice Address - Country:US
Practice Address - Phone:434-846-7374
Practice Address - Fax:434-846-1910
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA00012550801363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1063802312Medicaid
VAVVG526AMedicare PIN