Healthcare Provider Details

I. General information

NPI: 1720522873
Provider Name (Legal Business Name): KATHRYN MARIE SHINE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2016
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 NW CANAL BLVD
REDMOND OR
97756-1341
US

IV. Provider business mailing address

2800 SW 257TH AVE
TROUTDALE OR
97060-1803
US

V. Phone/Fax

Practice location:
  • Phone: 541-706-5800
  • Fax: 541-706-5800
Mailing address:
  • Phone: 503-667-7711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201607532NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: