Provider Demographics
NPI:1447578224
Name:HORNER, SHANNON (ARNP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HORNER
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 450
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-0450
Mailing Address - Country:US
Mailing Address - Phone:360-698-6022
Mailing Address - Fax:360-698-7002
Practice Address - Street 1:9321 RIDGETOP BLVD NW
Practice Address - Street 2:STE 100
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383
Practice Address - Country:US
Practice Address - Phone:360-782-3661
Practice Address - Fax:360-698-7002
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60130848363L00000X, 363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2007385Medicaid