Provider Demographics
NPI:1255596607
Name:WIEDEMAN, SHANNON ELIZABETH (NP AND RN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELIZABETH
Last Name:WIEDEMAN
Suffix:
Gender:F
Credentials:NP AND RN
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:ELIZABETH
Other - Last Name:PAYDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:207 SW 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-1203
Mailing Address - Country:US
Mailing Address - Phone:541-426-4524
Mailing Address - Fax:541-426-3035
Practice Address - Street 1:207 SW 1ST ST
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:OR
Practice Address - Zip Code:97828-1203
Practice Address - Country:US
Practice Address - Phone:541-426-0801
Practice Address - Fax:541-426-0802
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201050225NP363LA2200X
OR201043506RN163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500641038Medicaid
ORO10244476AAOtherREGENCE BLUE CROSS BLUE SHIELD
OR383864OtherMEDICARE RHC