MEDICARE: SANDRA D SHELLEY CRNA

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	367500000X	Certified Registered Nurse Anesthetist	18465	SC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00395317	OTHER	SC	RR MEDICARE
6	DE5998	OTHER	SC	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	204185222	OTHER	SC	BCBS OF SC
3	204185222	OTHER	SC	TRICARE
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790848364
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA D SHELLEY CRNA

Provider Business Mailing Address
First Line	:	4509 WOODLAND ST
Second Line	:
City	:	NORTH MYRTLE BEACH
State	:	SC
Zip	:	29582-5244
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3911 HIGHWAY 17 # B
Second Line	:
City	:	MURRELLS INLET
State	:	SC
Zip	:	29576-5014
Country	:	US
Telephone Number	:	843-651-8211
Fax Number	:

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

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	05/15/2008

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Directions to “ SANDRA D SHELLEY CRNA” Practice Location

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