Provider Demographics
NPI:1508048737
Name:KIDD, SHANNON M (CRNA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:KIDD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:M
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:2139 AUBURN AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2906
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:740-374-5887
Practice Address - Street 1:401 MATTHEW ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1635
Practice Address - Country:US
Practice Address - Phone:740-374-9990
Practice Address - Fax:740-374-9993
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-29
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV60137367500000X
OHCOA.11504.NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2937764Medicaid
OH000000666683OtherANTHEM
OH000000662146OtherANTHEM
WV3810014829Medicaid
OHP01058722OtherRAILROAD MEDICARE
WV8243673Medicare PIN
OH000000666683OtherANTHEM