Healthcare Provider Details

I. General information

NPI: 1457018301
Provider Name (Legal Business Name): SHAWNNA TREVETTE VAN SICKLE CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHAWNNA TREVETTE PHILLIPS

II. Dates (important events)

Enumeration Date: 11/24/2021
Last Update Date: 11/24/2021
Certification Date: 11/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 SW 37TH ST
PENDLETON OR
97801-3605
US

IV. Provider business mailing address

25117 SW PARKWAY AVE STE D
WILSONVILLE OR
97070-9697
US

V. Phone/Fax

Practice location:
  • Phone: 541-276-3374
  • Fax:
Mailing address:
  • Phone: 971-364-0611
  • Fax: 971-364-0610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

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: