Provider Demographics
NPI:1841502549
Name:SHANE, AIMEE (CRNA)
Entity type:Individual
Prefix:
First Name:AIMEE
Middle Name:
Last Name:SHANE
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 1:278 PIN OAK CT
Mailing Address - Street 2:
Mailing Address - City:DAHINDA
Mailing Address - State:IL
Mailing Address - Zip Code:61428-9769
Mailing Address - Country:US
Mailing Address - Phone:309-339-1259
Mailing Address - Fax:
Practice Address - Street 1:1051 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-8354
Practice Address - Country:US
Practice Address - Phone:309-852-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.008194367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
797940012Medicare PIN