Provider Demographics
NPI:1619288487
Name:SPEED, SHANDA (CRNA)
Entity Type:Individual
Prefix:
First Name:SHANDA
Middle Name:
Last Name:SPEED
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 1:408 WENDELL AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:MT
Mailing Address - Zip Code:59457-2261
Mailing Address - Country:US
Mailing Address - Phone:406-535-7711
Mailing Address - Fax:
Practice Address - Street 1:408 WENDELL AVE
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:MT
Practice Address - Zip Code:59457-2261
Practice Address - Country:US
Practice Address - Phone:406-535-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT083573163W00000X
MTNUR-APRN-LIC-101159367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400022567Medicare PIN