Provider Demographics
NPI:1255831483
Name:DITTLER, SHANNON RAY (RN)
Entity type:Individual
Prefix:MR
First Name:SHANNON
Middle Name:RAY
Last Name:DITTLER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4232 NE 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-3204
Mailing Address - Country:US
Mailing Address - Phone:971-275-3186
Mailing Address - Fax:
Practice Address - Street 1:4232 NE 62ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97218-3204
Practice Address - Country:US
Practice Address - Phone:971-275-3186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200642863RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse