Provider Demographics
NPI:1871142661
Name:SHEA, MOLLY TILLENE (CRNA)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:TILLENE
Last Name:SHEA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:TILLENE
Other - Last Name:SHEA-VILLARREAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 1309 - MAIL STOP 21110Q
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-1309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:MAIL STOP 11503P
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101
Practice Address - Country:US
Practice Address - Phone:651-254-6512
Practice Address - Fax:651-254-3048
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2389253367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered