Provider Demographics
NPI:1083722508
Name:FOUTCH, SHELLEY KAY (CRNA)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:KAY
Last Name:FOUTCH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:KAY
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 34310
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134
Mailing Address - Country:US
Mailing Address - Phone:402-778-9737
Mailing Address - Fax:402-334-2849
Practice Address - Street 1:6901 N 72 STREET
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68122
Practice Address - Country:US
Practice Address - Phone:402-572-2160
Practice Address - Fax:402-334-2849
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE100637367500000X
IAD101829367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470550438-15Medicaid
IA0520395Medicaid
IA0520395Medicaid
553454Medicare UPIN