Provider Demographics
NPI:1356957294
Name:PEERBOOM, SHANNON MARIE (ARNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:PEERBOOM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:DURHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3908 10TH ST SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-2188
Mailing Address - Country:US
Mailing Address - Phone:253-845-7073
Mailing Address - Fax:
Practice Address - Street 1:3908 10TH ST SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-2188
Practice Address - Country:US
Practice Address - Phone:253-845-7073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61092015363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner