Healthcare Provider Details

I. General information

NPI: 1710797253
Provider Name (Legal Business Name): SHANNON FRUCCI DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2025
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2265 EXCHANGE ST
ASTORIA OR
97103-3331
US

IV. Provider business mailing address

PO BOX 976
OCEAN PARK WA
98640-0976
US

V. Phone/Fax

Practice location:
  • Phone: 503-338-7555
  • Fax:
Mailing address:
  • Phone: 509-993-1760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP032260T
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number61522066
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: