Provider Demographics
NPI:1720522873
Name:SHINE, KATHRYN MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARIE
Last Name:SHINE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 SW 257TH AVE
Mailing Address - Street 2:
Mailing Address - City:TROUTDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97060-1803
Mailing Address - Country:US
Mailing Address - Phone:503-667-7711
Mailing Address - Fax:
Practice Address - Street 1:1541 NW CANAL BLVD
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1341
Practice Address - Country:US
Practice Address - Phone:541-706-5800
Practice Address - Fax:541-706-5800
Is Sole Proprietor?:No
Enumeration Date:2016-12-08
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201607532NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily