Provider Demographics
NPI:1679129753
Name:TRAMMELL, SHANNON DANETTE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:DANETTE
Last Name:TRAMMELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:DANETTE
Other - Last Name:MORHAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:954 SE TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-4330
Mailing Address - Country:US
Mailing Address - Phone:541-430-7012
Mailing Address - Fax:
Practice Address - Street 1:340 NW MEDICAL LOOP
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1645
Practice Address - Country:US
Practice Address - Phone:541-464-5907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA195503363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant