Healthcare Provider Details

I. General information

NPI: 1912952839
Provider Name (Legal Business Name): SHELLY DAWN FISHER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BRAMHALL ST
PORTLAND ME
04102-3175
US

IV. Provider business mailing address

PO BOX 171306
MEMPHIS TN
38187-1306
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-0111
  • Fax:
Mailing address:
  • Phone: 901-725-5846
  • Fax: 901-726-4827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number103254
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number758279
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA233008
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: