Healthcare Provider Details

I. General information

NPI: 1366230286
Provider Name (Legal Business Name): SHANNON ARLENE WYLAND QMHA-R
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2025
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 SW 7TH ST
REDMOND OR
97756-2113
US

IV. Provider business mailing address

215 SW 7TH ST
REDMOND OR
97756-2113
US

V. Phone/Fax

Practice location:
  • Phone: 541-388-8459
  • Fax: 541-388-8116
Mailing address:
  • Phone: 541-388-8459
  • Fax: 541-388-8116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: