Basic Information
| Provider Information | |||||||||
| NPI: | 1902030273 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNGBLOOD | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | LEONNIE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5887 | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 713075887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184425399 | ||||||||
| FaxNumber: | 3184421586 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 SAINT MARY PL | ||||||||
| Address2: | PFS-PRO BILLING | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711014343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186816878 | ||||||||
| FaxNumber: | 3186817402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2009 | ||||||||
| LastUpdateDate: | 04/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | AP05726 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.