Individual
MRS. TINA NANNETTE SHANNON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
3200 MACCORKLE AVE SE, CHARLESTON, WV 25304-1227
(304) 388-5503
Mailing address
311 SOUTHPOINTE DR, CHARLESTON, WV 25314-2471
(304) 546-3081
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
54626
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
001713630
BCBS-MAAC
WV
05
—
2601300000
—
WV
05
—
2624413
—
OH
01
—
270052997
TAX ID -MAAC
WV
01
—
27005299700
WORKER'S COMP-MAAC
WV
01
—
P00258571
MEDICARE
WV
Enumeration date
05/31/2005
Last updated
04/17/2024
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