Healthcare Provider Details

I. General information

NPI: 1093978892
Provider Name (Legal Business Name): SHELLEY RAE DAIGH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHELLY RAE SMITH

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 10/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E CARPENTER ST ROOM 2K64
SPRINGFIELD IL
62769-0001
US

IV. Provider business mailing address

800 E CARPENTER ST ROOM 2K64
SPRINGFIELD IL
62769-0001
US

V. Phone/Fax

Practice location:
  • Phone: 217-525-5643
  • Fax: 217-544-2521
Mailing address:
  • Phone: 217-525-5643
  • Fax: 217-544-2521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number041-273477
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: