1629278379 NPI number — SHANDREA RODRIGUEZ FNP

Table of content: SHANDREA RODRIGUEZ FNP (NPI 1629278379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629278379 NPI number — SHANDREA RODRIGUEZ FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RODRIGUEZ
Provider First Name:
SHANDREA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629278379
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
160 WAYLAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVIDENCE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02906-4304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-521-1221
Provider Business Mailing Address Fax Number:
401-454-4189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
WAYLAND MEDICAL ASSOCIATES
Provider Second Line Business Practice Location Address:
160 WAYLAND AVE
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-521-1221
Provider Business Practice Location Address Fax Number:
401-454-4189
Provider Enumeration Date:
07/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  RN42313 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: APRN01603 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: SR67488 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".




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