Provider Demographics
NPI:1295492791
Name:LA DOUCE, SHANNON (PMHNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:LA DOUCE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 COLUMBIA ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-7205
Mailing Address - Country:US
Mailing Address - Phone:503-707-1950
Mailing Address - Fax:
Practice Address - Street 1:945 COLUMBIA ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-7205
Practice Address - Country:US
Practice Address - Phone:503-707-1950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202112026NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health