Provider Demographics
NPI:1386184307
Name:OGDEN, SHANNON ELIZABETH (CRNA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:OGDEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:CAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:701 N 1ST ST
Mailing Address - Street 2:ANESTHESIA DEPT
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62781-0001
Mailing Address - Country:US
Mailing Address - Phone:217-788-3755
Mailing Address - Fax:217-788-7071
Practice Address - Street 1:530 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1675
Practice Address - Country:US
Practice Address - Phone:502-852-5851
Practice Address - Fax:502-852-3762
Is Sole Proprietor?:No
Enumeration Date:2017-02-24
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015641367500000X
KY3014992367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100693300Medicaid
111190OtherNBCRNA
IN300042865Medicaid