Provider Demographics
NPI:1770988115
Name:VANDER PLOEG, SHENA
Entity type:Individual
Prefix:
First Name:SHENA
Middle Name:
Last Name:VANDER PLOEG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21885 WILLAMETTE DR
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-3260
Mailing Address - Country:US
Mailing Address - Phone:201-230-2517
Mailing Address - Fax:
Practice Address - Street 1:905 SE ANKENY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1349
Practice Address - Country:US
Practice Address - Phone:971-236-7610
Practice Address - Fax:888-398-0996
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-28
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2019175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath