Provider Demographics
NPI:1902030273
Name:YOUNGBLOOD, SHANNON LEONNIE (CRNA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEONNIE
Last Name:YOUNGBLOOD
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:PO BOX 5887
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71307-5887
Mailing Address - Country:US
Mailing Address - Phone:318-442-5399
Mailing Address - Fax:318-442-1586
Practice Address - Street 1:1 SAINT MARY PL
Practice Address - Street 2:PFS-PRO BILLING
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4343
Practice Address - Country:US
Practice Address - Phone:318-681-6878
Practice Address - Fax:318-681-7402
Is Sole Proprietor?:No
Enumeration Date:2009-05-14
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP05726367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered