Provider Demographics
NPI:1689701872
Name:SHIVELY, CONNIE MICHELLE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:MICHELLE
Last Name:SHIVELY
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 1:420 RISER RD
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-9131
Mailing Address - Country:US
Mailing Address - Phone:318-232-7700
Mailing Address - Fax:318-232-1092
Practice Address - Street 1:1118 S FARMERVILLE ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5914
Practice Address - Country:US
Practice Address - Phone:318-723-2770
Practice Address - Fax:318-232-1092
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA60181367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5T808Medicare PIN