Provider Demographics
NPI:1689755811
Name:SHANNON, KATHY L (ARNP)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:L
Last Name:SHANNON
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 1:590 BOGACHIEL WAY
Mailing Address - Street 2:
Mailing Address - City:FORKS
Mailing Address - State:WA
Mailing Address - Zip Code:98331-9120
Mailing Address - Country:US
Mailing Address - Phone:360-374-6271
Mailing Address - Fax:360-374-9781
Practice Address - Street 1:590 BOGACHIEL WAY
Practice Address - Street 2:
Practice Address - City:FORKS
Practice Address - State:WA
Practice Address - Zip Code:98331-9120
Practice Address - Country:US
Practice Address - Phone:360-374-6271
Practice Address - Fax:360-374-9781
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006382363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP84894Medicare UPIN