Healthcare Provider Details

I. General information

NPI: 1154602746
Provider Name (Legal Business Name): SHANNON C RYAN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2011
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 OAK ST STE 205
CENTRAL POINT OR
97502-2542
US

IV. Provider business mailing address

312 OAK ST STE 205
CENTRAL POINT OR
97502-2542
US

V. Phone/Fax

Practice location:
  • Phone: 541-727-7787
  • Fax: 541-727-7529
Mailing address:
  • Phone: 541-727-7787
  • Fax: 541-727-7529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number099000570RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201600527NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: