Provider Demographics
NPI:1235400623
Name:DENICKE, SHELBY L (CRNA)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:L
Last Name:DENICKE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:L
Other - Last Name:RIVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 E CARPENTER ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62769-1000
Mailing Address - Country:US
Mailing Address - Phone:217-544-6464
Mailing Address - Fax:
Practice Address - Street 1:800 E CARPENTER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769-2417
Practice Address - Country:US
Practice Address - Phone:217-544-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012001557367500000X
IL209020424367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered