Provider Demographics
NPI:1841279379
Name:SHESTOPAL CHILDRES, NAOMI (CRNA)
Entity type:Individual
Prefix:
First Name:NAOMI
Middle Name:
Last Name:SHESTOPAL CHILDRES
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:NAOMI
Other - Middle Name:
Other - Last Name:SHESTOPAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:6914 77TH STREET CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-5595
Mailing Address - Country:US
Mailing Address - Phone:253-904-8654
Mailing Address - Fax:
Practice Address - Street 1:209 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4265
Practice Address - Country:US
Practice Address - Phone:253-596-3300
Practice Address - Fax:253-596-3301
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00103533367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN