Provider Demographics
NPI:1821098930
Name:HALL, SHANNON D DALE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:SHANNON D
Middle Name:DALE
Last Name:HALL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 URLACHER DR
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-8998
Mailing Address - Country:US
Mailing Address - Phone:615-796-0057
Mailing Address - Fax:
Practice Address - Street 1:500 COLLEGE ST
Practice Address - Street 2:YALE NEW HAVEN HOSPITAL
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-8962
Practice Address - Country:US
Practice Address - Phone:203-432-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN071173367500000X
CT003790367500000X
SC20635367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPENDINGMedicaid
KY74007634Medicaid
TN3634996Medicaid
TN4072296OtherBCBS NUMBER
KY74007634Medicaid
SCPENDINGMedicaid
TN3634996Medicare ID - Type Unspecified