Provider Demographics
NPI:1598094583
Name:HOLYOKE, SHANNON MARIE (RN, BSN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:HOLYOKE
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9425 N GENEVA AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-2648
Mailing Address - Country:US
Mailing Address - Phone:503-504-5040
Mailing Address - Fax:
Practice Address - Street 1:9425 N GENEVA AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-2648
Practice Address - Country:US
Practice Address - Phone:503-504-5040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-22
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200640590RN163WH0200X
OR200646590RN163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WP0200XNursing Service ProvidersRegistered NursePediatrics