=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568551448
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENDA C SHEALY CRNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2006
-----------------------------------------------------
Last Update Date | 04/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3801 S NATIONAL AVE
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65807-5210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-269-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125COUNTY ROAD 622
-----------------------------------------------------
City | OAK GROVE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-749-2097
-----------------------------------------------------
Fax | 870-749-2210
-----------------------------------------------------
=====================================================
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 | 075234
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | C01097
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------