Provider Demographics
NPI:1265562144
Name:KUDIALIS, SHELLEY J (CRNA)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:J
Last Name:KUDIALIS
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 1:230 LAKE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:JONESBOROUGH
Mailing Address - State:TN
Mailing Address - Zip Code:37659-4798
Mailing Address - Country:US
Mailing Address - Phone:423-438-0521
Mailing Address - Fax:
Practice Address - Street 1:1114 SUNSET DR
Practice Address - Street 2:SUITE 4
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2969
Practice Address - Country:US
Practice Address - Phone:423-283-0776
Practice Address - Fax:423-283-0549
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9387933367500000X
TNRN0000158056367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPENDINGMedicaid
TNPENDINGMedicaid