Healthcare Provider Details

I. General information

NPI: 1063751055
Provider Name (Legal Business Name): SHANNON CORBETT GLENN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2013
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11705 MERCY BLVD
SAVANNAH GA
31419-1711
US

IV. Provider business mailing address

PO BOX 551420
FORT LAUDERDALE FL
33355-1420
US

V. Phone/Fax

Practice location:
  • Phone: 912-819-4100
  • Fax:
Mailing address:
  • Phone: 800-243-3839
  • Fax: 954-839-2569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN152340
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: