Basic Information
| Provider Information | |||||||||
| NPI: | 1427306703 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHOULDIS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARLESS | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP-C | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 210 BROOKS ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043881930 | ||||||||
| FaxNumber: | 3043881929 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 BROOKS ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043881930 | ||||||||
| FaxNumber: | 3043881929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2012 | ||||||||
| LastUpdateDate: | 05/08/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 64722 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3810023952 | 05 | WV | MEDICAID | WV1751A | 01 | WV | MEDICARE PTAN | OTHER |