Provider Demographics
NPI:1205893328
Name:REYNOLDS, SHARON ELIZABETH (MN, FNP)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:ELIZABETH
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MN, FNP
Other - Prefix:
Other - First Name:SHARON
Other - Middle Name:ELIZABETH
Other - Last Name:RUPERT UNDERWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MN, FNP
Mailing Address - Street 1:2999 NE 181ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-6923
Mailing Address - Country:US
Mailing Address - Phone:503-401-5201
Mailing Address - Fax:503-401-3322
Practice Address - Street 1:2999 NE 181ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-6923
Practice Address - Country:US
Practice Address - Phone:503-401-5201
Practice Address - Fax:503-401-3322
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00068423163W00000X
OR201240347RN163W00000X
OR201250019NP363LF0000X
WAAP30003947363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q49212Medicare UPIN
WA8538773Medicare ID - Type Unspecified