Provider Demographics
NPI:1861455693
Name:STAFFORD, SHIRLEY (CRNA)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:STAFFORD
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 1:501 20TH ST
Mailing Address - Street 2:SUITE 606
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-1809
Mailing Address - Country:US
Mailing Address - Phone:865-546-8040
Mailing Address - Fax:
Practice Address - Street 1:501 20TH ST
Practice Address - Street 2:SUITE 606
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-1809
Practice Address - Country:US
Practice Address - Phone:865-546-8040
Practice Address - Fax:865-541-2787
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20291367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4020532OtherBLUE CROSS
TN4020532OtherBLUECARE
TN3603453Medicaid
TN430067798OtherTRAVELERS MEDICARE
TN100010926OtherPHP TENNCARE
TN4020532OtherBLUE CROSS