Provider Demographics
NPI:1366456832
Name:SHANE, SUSAN LEE (ARNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEE
Last Name:SHANE
Suffix:
Gender:F
Credentials:ARNP
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 153
Mailing Address - Street 2:411 CALAWAH
Mailing Address - City:FORKS
Mailing Address - State:WA
Mailing Address - Zip Code:98331-0153
Mailing Address - Country:US
Mailing Address - Phone:360-374-9180
Mailing Address - Fax:360-374-3162
Practice Address - Street 1:390 FOUNDERS WAY
Practice Address - Street 2:SUITE 1
Practice Address - City:FORKS
Practice Address - State:WA
Practice Address - Zip Code:98331-9062
Practice Address - Country:US
Practice Address - Phone:360-374-9180
Practice Address - Fax:360-374-3162
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00050684163WW0101X
WAAP30000331364SW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SW0102XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's Health
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9607458Medicaid
WA503999Medicare ID - Type Unspecified
WA9607458Medicaid