Provider Demographics
NPI:1912952839
Name:FISHER, SHELLY DAWN (CRNA)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:DAWN
Last Name:FISHER
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:PO BOX 171306
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38187-1306
Mailing Address - Country:US
Mailing Address - Phone:901-725-5846
Mailing Address - Fax:901-726-4827
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3175
Practice Address - Country:US
Practice Address - Phone:207-662-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN103254174400000X
NY758279367500000X
MERNA233008367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3629385Medicaid
MERNA233008OtherMAINE APRN LICENSE
49727OtherNATIONAL BOARD CERTIFICATION OF NURSE ANETHETIST