Provider Demographics
NPI:1003868985
Name:NOBLIN, SHANNON N (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:N
Last Name:NOBLIN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1900 EXETER RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2954
Mailing Address - Country:US
Mailing Address - Phone:901-818-2160
Mailing Address - Fax:901-682-9522
Practice Address - Street 1:1900 EXETER RD
Practice Address - Street 2:SUITE 210
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-2954
Practice Address - Country:US
Practice Address - Phone:901-818-2160
Practice Address - Fax:901-682-9522
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN 123066163W00000X
TNAPN 12008367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO911170702Medicaid
TN3636150Medicaid
TNP00292170OtherRR MEDICARE
TN4124941OtherBCBSTN
MS02434069Medicaid
AR167792001Medicaid
TN3636150Medicare ID - Type Unspecified