Provider Demographics
NPI:1912885500
Name:LANTZ, SHANNON (CRNA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:LANTZ
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:COSTELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:163 CROOKED CREEK LN
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:TN
Mailing Address - Zip Code:38355-8931
Mailing Address - Country:US
Mailing Address - Phone:508-209-3003
Mailing Address - Fax:
Practice Address - Street 1:620 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3923
Practice Address - Country:US
Practice Address - Phone:731-541-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-22
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN155447367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered