Healthcare Provider Details

I. General information

NPI: 1174875827
Provider Name (Legal Business Name): SHANNON NICOLE DAVIDSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON BENNETT

II. Dates (important events)

Enumeration Date: 10/04/2012
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SW 10TH AVE
TOPEKA KS
66604-1301
US

IV. Provider business mailing address

823 SW MULVANE ST
TOPEKA KS
66606-1764
US

V. Phone/Fax

Practice location:
  • Phone: 785-235-3451
  • Fax:
Mailing address:
  • Phone: 785-235-3451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number99055
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4416
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: