Healthcare Provider Details

I. General information

NPI: 1689701872
Provider Name (Legal Business Name): CONNIE MICHELLE SHIVELY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 S FARMERVILLE ST
RUSTON LA
71270-5914
US

IV. Provider business mailing address

420 RISER RD
RUSTON LA
71270-9131
US

V. Phone/Fax

Practice location:
  • Phone: 318-723-2770
  • Fax: 318-232-1092
Mailing address:
  • Phone: 318-232-7700
  • Fax: 318-232-1092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number60181
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: