Healthcare Provider Details

I. General information

NPI: 1780697565
Provider Name (Legal Business Name): SHANE L NELSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 05/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N HOLTZCLAW AVE
CHATTANOOGA TN
37404-1916
US

IV. Provider business mailing address

425 LEWIS HARGETT CIR
LEXINGTON KY
40503-3590
US

V. Phone/Fax

Practice location:
  • Phone: 423-698-6871
  • Fax:
Mailing address:
  • Phone: 859-268-1030
  • Fax: 859-269-4120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number116935
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: