Provider Demographics
NPI:1417298084
Name:WRIGHT, SHANA RUTKOWSKI (CRNP)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:RUTKOWSKI
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:SHANA
Other - Middle Name:RUTKOWSKI
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2400 GORDON SMITH DR
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36617-2319
Mailing Address - Country:US
Mailing Address - Phone:251-473-4423
Mailing Address - Fax:
Practice Address - Street 1:2400 GORDON SMITH DR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36617-2319
Practice Address - Country:US
Practice Address - Phone:251-473-4423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-07
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-126404363LP0808X
OHAPRN.CNP.021374363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0243692Medicaid