Basic Information
| Provider Information | |||||||||
| NPI: | 1508048737 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIDD | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JENKINS | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2139 AUBURN AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403744500 | ||||||||
| FaxNumber: | 7403745887 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 MATTHEW ST | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457501635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403749990 | ||||||||
| FaxNumber: | 7403749993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2007 | ||||||||
| LastUpdateDate: | 03/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 60137 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | COA.11504.NA | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 2937764 | 05 | OH | MEDICAID | 000000666683 | 01 | OH | ANTHEM | OTHER | 000000662146 | 01 | OH | ANTHEM | OTHER | 3810014829 | 05 | WV | MEDICAID | P01058722 | 01 | OH | RAILROAD MEDICARE | OTHER |