Healthcare Provider Details

I. General information

NPI: 1477955763
Provider Name (Legal Business Name): SHELLY ALVARADO CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 09/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3906 TWILIGHT AVE
ENID OK
73703-3613
US

IV. Provider business mailing address

3906 TWILIGHT AVE
ENID OK
73703-3613
US

V. Phone/Fax

Practice location:
  • Phone: 580-554-4725
  • Fax:
Mailing address:
  • Phone: 580-554-4725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR0062520
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: