Basic Information
| Provider Information | |||||||||
| NPI: | 1588171482 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHEA | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | VICTORIA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6412 WESLEY LN | ||||||||
| Address2: | |||||||||
| City: | ELKRIDGE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210755958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4438895513 | ||||||||
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| Practice Location | |||||||||
| Address1: | 40 S DUNDALK AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102200720 | ||||||||
| FaxNumber: | 4108620150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2018 | ||||||||
| LastUpdateDate: | 05/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R192781 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 212220100 | 05 | MD | MEDICAID |