Provider Demographics
NPI:1861199184
Name:MALLERY, SHAHAUNA LATIA (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:SHAHAUNA
Middle Name:LATIA
Last Name:MALLERY
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 1:238 BATTLEFIELD BLVD S STE 200
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-5233
Mailing Address - Country:US
Mailing Address - Phone:757-330-2491
Mailing Address - Fax:757-974-0041
Practice Address - Street 1:238 BATTLEFIELD BLVD S STE 200
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23322-5233
Practice Address - Country:US
Practice Address - Phone:757-330-2491
Practice Address - Fax:757-974-0041
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-08
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024186470363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024186470OtherVIRGINIA DEPARTMENT OF HEALTH PROFESSIONS
VA0001227876OtherVIRGINIA DEPARTMENT OF HEALTH PROFESSIONS