Provider Demographics
NPI:1588171482
Name:SHEA, JACQUELINE VICTORIA (NP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:VICTORIA
Last Name:SHEA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6412 WESLEY LN
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-5958
Mailing Address - Country:US
Mailing Address - Phone:443-889-5513
Mailing Address - Fax:
Practice Address - Street 1:40 S DUNDALK AVE STE 400
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21222
Practice Address - Country:US
Practice Address - Phone:410-220-0720
Practice Address - Fax:410-862-0150
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR192781363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD212220100Medicaid