Provider Demographics
NPI:1083006522
Name:BOLT, SHANNON ELOISE (ARNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELOISE
Last Name:BOLT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:ELOISE
Other - Last Name:REIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4209 TIETON DR
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3377
Mailing Address - Country:US
Mailing Address - Phone:509-654-9810
Mailing Address - Fax:509-966-8812
Practice Address - Street 1:4209 TIETON DR
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3377
Practice Address - Country:US
Practice Address - Phone:509-654-9810
Practice Address - Fax:509-966-8812
Is Sole Proprietor?:No
Enumeration Date:2015-02-20
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60528267163W00000X
WAAP61369683363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP61369683OtherWASHINGTON STATE DEPARTMENT OF HEALTH
WARN60528267OtherWASHINGTON STATE DEPARTMENT OF HEALTH
F10220605OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION BOARD