Healthcare Provider Details

I. General information

NPI: 1861217192
Provider Name (Legal Business Name): KASI LYNN SHOCK RN, CA-SANE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2024
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

387 W IH 10
FORT STOCKTON TX
79735-2708
US

IV. Provider business mailing address

1400 N OKLAHOMA ST
FORT STOCKTON TX
79735-2631
US

V. Phone/Fax

Practice location:
  • Phone: 432-336-2004
  • Fax:
Mailing address:
  • Phone: 432-290-8970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number1003645
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: