Provider Demographics
NPI:1013488220
Name:MONTELEONE, SHANNON LYNNE (CRNA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:LYNNE
Last Name:MONTELEONE
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 1:111 ACORN ST
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-8818
Mailing Address - Country:US
Mailing Address - Phone:912-656-6619
Mailing Address - Fax:
Practice Address - Street 1:2415 PARKWOOD DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4722
Practice Address - Country:US
Practice Address - Phone:912-466-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27094367500000X
MO2022035596367500000X
GARN230853367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN3611Medicaid