Provider Demographics
NPI:1629430228
Name:BRUCE OWEN, SHANETTE
Entity Type:Individual
Prefix:
First Name:SHANETTE
Middle Name:
Last Name:BRUCE OWEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANETTE
Other - Middle Name:JEAN
Other - Last Name:OWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6351 W RIO GRANDE AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7634
Mailing Address - Country:US
Mailing Address - Phone:509-543-9280
Mailing Address - Fax:509-579-5915
Practice Address - Street 1:6351 W RIO GRANDE AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7634
Practice Address - Country:US
Practice Address - Phone:509-543-9280
Practice Address - Fax:509-579-5915
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOL60849496207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1629430228Medicaid