Basic Information
Provider Information | |||||||||
NPI: | 1730325762 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JONES | ||||||||
FirstName: | SHANERICKA | ||||||||
MiddleName: | RESHONET | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JONES | ||||||||
OtherFirstName: | CISSY | ||||||||
OtherMiddleName: | RESHONET | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNA | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 37090 | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212973090 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7032959360 | ||||||||
FaxNumber: | 7032959369 | ||||||||
Practice Location | |||||||||
Address1: | 3998 FAIR RIDGE DRIVE | ||||||||
Address2: | SUITE 320 | ||||||||
City: | FAIRFAX | ||||||||
State: | VA | ||||||||
PostalCode: | 220332921 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7032959360 | ||||||||
FaxNumber: | 7032959369 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/22/2008 | ||||||||
LastUpdateDate: | 08/28/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 157231 | TN | N |   | Nursing Service Providers | Registered Nurse |   | 367500000X | 13884 | TN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | 0024171084 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | P00711618 | 01 | TN | RAILROAD MEDICARE | OTHER | 04870087 | 05 | MS |   | MEDICAID | 1511595 | 05 | TN |   | MEDICAID | 1730325762 | 01 |   | CHAMPUS/HUMANA TRICARE | OTHER | 186289001 | 05 | AR |   | MEDICAID | 4205212 | 01 | TN | BLUE CROSS | OTHER |