Provider Demographics
NPI:1134813405
Name:THURSTON, SHANNON (CNM)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:THURSTON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:DULETZKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:24850 SE STARK ST STE 200
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-8320
Mailing Address - Country:US
Mailing Address - Phone:503-491-9444
Mailing Address - Fax:
Practice Address - Street 1:24850 SE STARK ST STE 200
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-8320
Practice Address - Country:US
Practice Address - Phone:503-491-9444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-07
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10009305176B00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife