Provider Demographics
NPI:1487498630
Name:KING, SHAVANNA (PMHNP- BC)
Entity type:Individual
Prefix:MRS
First Name:SHAVANNA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:PMHNP- BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 CHANCELLOR DR W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-8143
Mailing Address - Country:US
Mailing Address - Phone:904-420-9724
Mailing Address - Fax:
Practice Address - Street 1:1620 CORSAIR LN STE 201
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-8558
Practice Address - Country:US
Practice Address - Phone:904-787-8850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-22
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9394466163W00000X
FLAPRN11033411363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse