Provider Demographics
NPI:1114339389
Name:MARSH, SHANNON M (APRN)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:M
Last Name:MARSH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 877
Mailing Address - Street 2:
Mailing Address - City:ILWACO
Mailing Address - State:WA
Mailing Address - Zip Code:98624-0877
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:176 1ST AVE N
Practice Address - Street 2:PO BOX N
Practice Address - City:ILWACO
Practice Address - State:WA
Practice Address - Zip Code:98624-9137
Practice Address - Country:US
Practice Address - Phone:360-642-3747
Practice Address - Fax:360-642-3361
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60562578364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8943805Medicare PIN