Provider Demographics
NPI:1275088627
Name:KING, SHANNON NICOLE (MS)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:NICOLE
Last Name:KING
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 POTTERY AVE
Mailing Address - Street 2:PORT ORCHARD MEDICAL CENTER
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-3768
Mailing Address - Country:US
Mailing Address - Phone:360-895-5000
Mailing Address - Fax:360-895-5034
Practice Address - Street 1:330 MADISON AVE S STE 106
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-2544
Practice Address - Country:US
Practice Address - Phone:206-451-3084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60698639235Z00000X
WASLPI.SI.60604417390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program