Provider Demographics
NPI:1003052499
Name:ERIKSSON, SHELLY RENE (CRNA)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:RENE
Last Name:ERIKSSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1737 BRIARCREST DR
Mailing Address - Street 2:SUITE 14
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2769
Mailing Address - Country:US
Mailing Address - Phone:979-776-4777
Mailing Address - Fax:979-776-0588
Practice Address - Street 1:1737 BRIARCREST DR
Practice Address - Street 2:SUITE 14
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2769
Practice Address - Country:US
Practice Address - Phone:979-776-4777
Practice Address - Fax:979-776-0588
Is Sole Proprietor?:No
Enumeration Date:2009-01-06
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX081106367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX199221601Medicaid
TX8L7982Medicare PIN