Healthcare Provider Details

I. General information

NPI: 1386184307
Provider Name (Legal Business Name): SHANNON ELIZABETH OGDEN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON CAIN CRNA

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 S JACKSON ST
LOUISVILLE KY
40202-1675
US

IV. Provider business mailing address

701 N 1ST ST ANESTHESIA DEPT
SPRINGFIELD IL
62781-0001
US

V. Phone/Fax

Practice location:
  • Phone: 502-852-5851
  • Fax: 502-852-3762
Mailing address:
  • Phone: 217-788-3755
  • Fax: 217-788-7071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209015641
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3014992
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: