Provider Demographics
NPI:1316922826
Name:EKBERG-SHELLEY, JANICE ELIZABETH (CRNA)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:ELIZABETH
Last Name:EKBERG-SHELLEY
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 1:2195 WESTOVER DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-9503
Mailing Address - Country:US
Mailing Address - Phone:434-812-1008
Mailing Address - Fax:434-823-1008
Practice Address - Street 1:1215 LEE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0816
Practice Address - Country:US
Practice Address - Phone:434-982-0655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001072985163W00000X
VA0024072985367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8938229Medicaid
VA8938229Medicaid
VA430001619Medicare ID - Type Unspecified