Provider Demographics
NPI:1679620967
Name:ALLEN, SHARI LAVIDA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SHARI
Middle Name:LAVIDA
Last Name:ALLEN
Suffix:
Gender:F
Credentials:FNP
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 198
Mailing Address - Street 2:PO BOX 748
Mailing Address - City:CANYONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97417-0198
Mailing Address - Country:US
Mailing Address - Phone:541-839-4211
Mailing Address - Fax:541-839-4858
Practice Address - Street 1:115 SW PINE STREET
Practice Address - Street 2:
Practice Address - City:CANYONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97417-0198
Practice Address - Country:US
Practice Address - Phone:541-839-4211
Practice Address - Fax:541-839-4858
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200050018NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR268782Medicaid
ORR111733Medicare PIN
ORP49204Medicare UPIN