Provider Demographics
NPI:1588686612
Name:AVERITT, SHAZEEDA (CRNA)
Entity type:Individual
Prefix:
First Name:SHAZEEDA
Middle Name:
Last Name:AVERITT
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 1:621 RIDGELY AVENUE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401
Mailing Address - Country:US
Mailing Address - Phone:410-266-1588
Mailing Address - Fax:410-266-6931
Practice Address - Street 1:621 RIDGELY AVENUE
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401
Practice Address - Country:US
Practice Address - Phone:410-266-1588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR198233367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00943324AMedicaid
GA43ZCBFQ63Medicare ID - Type Unspecified