Provider Demographics
NPI:1336200682
Name:CALDWELL, SHANA KAY (RN, MSN, CPNP)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:KAY
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:RN, MSN, CPNP
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 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:305 W RUSK ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1514
Practice Address - Country:US
Practice Address - Phone:903-592-7304
Practice Address - Fax:903-592-1288
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX687871363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX186970303Medicaid
TX186970302Medicaid
TX280453YQ98Medicare PIN
TX186970303Medicaid