Provider Demographics
NPI:1730644790
Name:SULLIVAN, SHAINA MARIE
Entity Type:Individual
Prefix:
First Name:SHAINA
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10095 NW CURTIS ST
Mailing Address - Street 2:
Mailing Address - City:NORTH PLAINS
Mailing Address - State:OR
Mailing Address - Zip Code:97133-8201
Mailing Address - Country:US
Mailing Address - Phone:971-227-3630
Mailing Address - Fax:
Practice Address - Street 1:12370 SW 1ST ST
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2847
Practice Address - Country:US
Practice Address - Phone:503-644-3614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4434ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty