Provider Demographics
NPI:1154686814
Name:SMITH, SHANNON LEE (PMHNP, MPH)
Entity Type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:PMHNP, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 NW 6TH AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3964
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:619 NW 6TH AVE FL 3
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3964
Practice Address - Country:US
Practice Address - Phone:503-988-5020
Practice Address - Fax:503-988-5022
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201250082NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR22959Medicaid
OR22959Medicaid