Provider Demographics
NPI:1871976449
Name:SHOCKEY, JENNIFER ROSE (CRNA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:SHOCKEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ROSE
Other - Last Name:DUNCAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2897
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-2897
Mailing Address - Country:US
Mailing Address - Phone:877-649-7812
Mailing Address - Fax:918-392-2941
Practice Address - Street 1:929 N SAINT FRANCIS ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3821
Practice Address - Country:US
Practice Address - Phone:316-268-5000
Practice Address - Fax:316-291-4272
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS103365163W00000X
KS557366367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201119470AMedicaid
KS110017107Medicare PIN