Provider Demographics
NPI:1174858484
Name:CONRAD, SHANNON (LAC)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:CONRAD
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5532 SE KNIGHT STREET
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206
Mailing Address - Country:US
Mailing Address - Phone:503-453-3577
Mailing Address - Fax:503-455-4402
Practice Address - Street 1:1910 SE 11TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-4707
Practice Address - Country:US
Practice Address - Phone:503-208-6327
Practice Address - Fax:503-455-4402
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-05
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR140952171100000X
ORAC140952171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist