Provider Demographics
NPI:1730112814
Name:GLINIECKI, SHANA M (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:SHANA
Middle Name:M
Last Name:GLINIECKI
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SHANA
Other - Middle Name:M
Other - Last Name:SAEGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1702 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:701-364-4222
Mailing Address - Fax:
Practice Address - Street 1:400 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1951
Practice Address - Country:US
Practice Address - Phone:218-786-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI146853-030163W00000X
WI075700367500000X
MNCRNA2135367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44355600Medicaid
WI2886-033OtherAPNP LICENSE
WI2886-033OtherAPNP LICENSE