Healthcare Provider Details

I. General information

NPI: 1427475839
Provider Name (Legal Business Name): JESSICA ASHLEY SHIELDS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2014
Last Update Date: 07/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3916 BEN FRANKLIN BLVD
DURHAM NC
27704
US

IV. Provider business mailing address

2446 MEDWAY DR
RALEIGH NC
27608-1613
US

V. Phone/Fax

Practice location:
  • Phone: 919-384-0700
  • Fax:
Mailing address:
  • Phone: 919-384-0700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number236358
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number102592
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: