Provider Demographics
NPI:1922713254
Name:OVERTON, SHAVONNE LARCENIA
Entity type:Individual
Prefix:
First Name:SHAVONNE
Middle Name:LARCENIA
Last Name:OVERTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 745254
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-5254
Mailing Address - Country:US
Mailing Address - Phone:773-352-1515
Mailing Address - Fax:
Practice Address - Street 1:158 AMITY RD # 280
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06515-1405
Practice Address - Country:US
Practice Address - Phone:203-404-3463
Practice Address - Fax:203-563-9255
Is Sole Proprietor?:No
Enumeration Date:2023-01-20
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12.011424363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily