=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184696429
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANNON M THOMAS CRNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 MIMS RD
-----------------------------------------------------
City | SYLVANIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30467-1994
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-564-5253
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 784 SWEET BAY CT
-----------------------------------------------------
City | EVANS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30809-4469
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-863-4915
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | RN112820
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------