Basic Information
Provider Information
NPI: 1003143843
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SHINGLES
FirstName: ANTONNI
MiddleName: LASHAE
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1360 BEAVER TRAIL DR
Address2:  
City: CORDOVA
State: TN
PostalCode: 380169601
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 1360 BEAVER TRAIL DR
Address2:  
City: CORDOVA
State: TN
PostalCode: 380169601
CountryCode: US
TelephoneNumber: 9017542927
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/16/2009
LastUpdateDate: 07/11/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
163W00000XRN 149251TNN Nursing Service ProvidersRegistered Nurse 
367500000X14807TNY Physician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered 

ID Information
IDTypeStateIssuerDescription
100314384301 CHAMPUS/TRICAREOTHER
151946305TN MEDICAID
18702600101ARARKANSAS MEDICAIDOTHER
425285101TNBLUE CROSS OF TNOTHER


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