Provider Demographics
NPI:1013919547
Name:SHEAHAN, THERESA GAYLE (CRNA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:GAYLE
Last Name:SHEAHAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:G
Other - Last Name:SHEAHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:4069 BERRY CIR
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-6361
Mailing Address - Country:US
Mailing Address - Phone:850-723-4372
Mailing Address - Fax:
Practice Address - Street 1:4069 BERRY CIR
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-6361
Practice Address - Country:US
Practice Address - Phone:850-723-4372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9174463367500000X
IL209015976367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL430077530OtherRAILROAD MEDICARE
AL009900445Medicaid
FL304864100Medicaid
AL59174082OtherBLUE CROSS & BLUE SHIELD
FLG2809OtherBLUE CROSS & BLUE SHIELD
FLG2809YMedicare PIN