Basic Information
| Provider Information | |||||||||
| NPI: | 1265562144 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUDIALIS | ||||||||
| FirstName: | SHELLEY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 230 LAKE RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | JONESBOROUGH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376594798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234380521 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1114 SUNSET DR | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232830776 | ||||||||
| FaxNumber: | 4232830549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 10/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | APRN9387933 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | RN0000158056 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | TN | MEDICAID |