MEDICARE: JACQUELINE S SHRIVER CRNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LW0102X	Women's Health Nurse Practitioner	NP2122	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9934723	OTHER	OH	GROUP MEDICARE
4	H561340	OTHER	OH	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	1184652539	OTHER	OH	GROUP NPI
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	34-1689161	OTHER	OH	GROUP TAX ID

General Provider Information

NPI Number	:	1083606610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE S SHRIVER CRNP

Provider Business Mailing Address
First Line	:	200 SAINT CLAIR AVE
Second Line	:
City	:	SAINT MARYS
State	:	OH
Zip	:	45885-2400
Country	:	US
Telephone Number	:	419-300-1129
Fax Number	:	419-394-9575

Provider Business Practice Location Address
First Line	:	1140 S KNOXVILLE AVE STE B
Second Line	:
City	:	SAINT MARYS
State	:	OH
Zip	:	45885-2609
Country	:	US
Telephone Number	:	419-394-7314
Fax Number	:	419-394-7313

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2005
Last Update Date	:	04/19/2021

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