Healthcare Provider Details

I. General information

NPI: 1699245035
Provider Name (Legal Business Name): EMILY ROSE SHANNON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2018
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5812
US

IV. Provider business mailing address

1315 EAST BLVD UNIT 306
CHARLOTTE NC
28203-5978
US

V. Phone/Fax

Practice location:
  • Phone: 704-355-2000
  • Fax:
Mailing address:
  • Phone: 407-312-4711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number287481
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: