Provider Demographics
NPI:1114924008
Name:ALLEN, SHANNON MICHELLE (CRNA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MICHELLE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MICHELLE
Other - Last Name:GERWICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1600 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260-2830
Mailing Address - Country:US
Mailing Address - Phone:575-396-6611
Mailing Address - Fax:
Practice Address - Street 1:1600 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260
Practice Address - Country:US
Practice Address - Phone:575-396-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2018-11-08
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-12-28
Provider Licenses
StateLicense IDTaxonomies
NMCRNA00343367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM32951736Medicaid
NM32951736Medicaid