Provider Demographics
NPI:1003908120
Name:SHOTZ, KIMBERLY SUSAN (WHCNP, LAC)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:SUSAN
Last Name:SHOTZ
Suffix:
Gender:F
Credentials:WHCNP, LAC
Other - Prefix:
Other - First Name:KIMO
Other - Middle Name:
Other - Last Name:SHOTZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:WHCNP-BC, RN, LAC
Mailing Address - Street 1:6018 SE STARK ST
Mailing Address - Street 2:STE 103
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1990
Mailing Address - Country:US
Mailing Address - Phone:503-318-3352
Mailing Address - Fax:503-802-7321
Practice Address - Street 1:5050 NE HOYT ST STE 353
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2983
Practice Address - Country:US
Practice Address - Phone:503-297-4123
Practice Address - Fax:503-297-0344
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC156829171100000X
OROR 093006979N7363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No171100000XOther Service ProvidersAcupuncturist