MEDICARE: ROSALIE CACANINDIN SHEPARD CRNAP

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	207L00000X	Anesthesiology Physician	0024164751	VA
2	367500000X	Certified Registered Nurse Anesthetist	0024164751	VA

General Provider Information

NPI Number	:	1598765463
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSALIE CACANINDIN SHEPARD CRNAP

Provider Business Mailing Address
First Line	:	1817 CORAL BAY CT
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-2879
Country	:	US
Telephone Number	:	757-581-1072
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 COLISEUM DR
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23666-5963
Country	:	US
Telephone Number	:	757-736-3325
Fax Number	:

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

Provider Enumeration Date	:	07/21/2005
Last Update Date	:	05/23/2023

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