Provider Demographics
NPI:1043619547
Name:GUMBS, SHAVONNE MARIE (MSN, FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:SHAVONNE
Middle Name:MARIE
Last Name:GUMBS
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:MS
Other - First Name:SHAVONNE
Other - Middle Name:MARIE
Other - Last Name:SALAAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4921 COLLINGTONS BOUNTY DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-5627
Mailing Address - Country:US
Mailing Address - Phone:240-645-9037
Mailing Address - Fax:240-645-9037
Practice Address - Street 1:6111 HIGH BRIDGE RD
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-5216
Practice Address - Country:US
Practice Address - Phone:301-503-1490
Practice Address - Fax:301-576-5197
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR190102363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD636003300Medicaid