Provider Demographics
NPI:1023125424
Name:ANGEL, SHANNA LEE (ARNP)
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:LEE
Last Name:ANGEL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:SHANNA
Other - Middle Name:LEE
Other - Last Name:HADLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 508
Mailing Address - Street 2:
Mailing Address - City:MOSSYROCK
Mailing Address - State:WA
Mailing Address - Zip Code:98564-0508
Mailing Address - Country:US
Mailing Address - Phone:360-496-3702
Mailing Address - Fax:496-983-3098
Practice Address - Street 1:521 ADAMS
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:WA
Practice Address - Zip Code:98356
Practice Address - Country:US
Practice Address - Phone:360-496-5112
Practice Address - Fax:360-496-3511
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005616367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOTH000OtherUNIVERSAL UPIN