Provider Demographics
NPI:1184925299
Name:BERKS, SHANNON MARY (CRNA)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARY
Last Name:BERKS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 HADDON AVE
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-3101
Mailing Address - Country:US
Mailing Address - Phone:856-757-3836
Mailing Address - Fax:
Practice Address - Street 1:502 CENTENNIAL BLVD STE 1
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-9544
Practice Address - Country:US
Practice Address - Phone:856-874-0790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR12170800367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered