Provider Demographics
NPI:1447857552
Name:SHADWICK, NICOLE GENEVIEVE (CRNA)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:GENEVIEVE
Last Name:SHADWICK
Suffix:
Gender:F
Credentials:CRNA
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Other - First Name:
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:CB 8054
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:800-862-9980
Mailing Address - Fax:314-362-1185
Practice Address - Street 1:101 CIVIC CENTER LN
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5607
Practice Address - Country:US
Practice Address - Phone:928-855-8185
Practice Address - Fax:928-453-0453
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA95002021367500000X
FLAPRN11022686367500000X
MO2022021771367500000X
TX1026890367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO910112970Medicaid