Provider Demographics
NPI:1568551448
Name:SHEALY, BRENDA C (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:C
Last Name:SHEALY
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 1:125COUNTY ROAD 622
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:AR
Mailing Address - Zip Code:72660
Mailing Address - Country:US
Mailing Address - Phone:870-749-2097
Mailing Address - Fax:870-749-2210
Practice Address - Street 1:3801 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5210
Practice Address - Country:US
Practice Address - Phone:417-269-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO075234367500000X
ARC01097367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5W341Medicare PIN