Healthcare Provider Details

I. General information

NPI: 1134813405
Provider Name (Legal Business Name): SHANNON THURSTON CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON DULETZKE RN

II. Dates (important events)

Enumeration Date: 06/07/2023
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24850 SE STARK ST STE 200
GRESHAM OR
97030-8320
US

IV. Provider business mailing address

24850 SE STARK ST STE 200
GRESHAM OR
97030-8320
US

V. Phone/Fax

Practice location:
  • Phone: 503-491-9444
  • Fax:
Mailing address:
  • Phone: 503-491-9444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number10009305
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number10009305
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: