Provider Demographics
NPI:1891702692
Name:SHAH, KALYANI SUDHIR (NP)
Entity type:Individual
Prefix:MRS
First Name:KALYANI
Middle Name:SUDHIR
Last Name:SHAH
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 1:34 POPLAR FOREST DR
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-2070
Mailing Address - Country:US
Mailing Address - Phone:434-426-1765
Mailing Address - Fax:
Practice Address - Street 1:125 NATIONWIDE DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-4272
Practice Address - Country:US
Practice Address - Phone:434-200-6933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024070079363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAS35307Medicare UPIN