Provider Demographics
NPI:1437421773
Name:STATEN, SHANNON LACEY (CRNA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LACEY
Last Name:STATEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1303
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-1303
Mailing Address - Country:US
Mailing Address - Phone:912-538-5537
Mailing Address - Fax:912-538-5228
Practice Address - Street 1:1 MEADOWS PKWY
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8759
Practice Address - Country:US
Practice Address - Phone:912-538-5537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-02
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN188967367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered