Provider Demographics
NPI:1306568936
Name:KASHURBA, JENNIFER (FNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KASHURBA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:DISEATI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15100 MONKS PL
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-2080
Mailing Address - Country:US
Mailing Address - Phone:571-334-9404
Mailing Address - Fax:
Practice Address - Street 1:13710 ST FRANCIS BLVD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-3267
Practice Address - Country:US
Practice Address - Phone:804-594-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024185185363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner