Healthcare Provider Details

I. General information

NPI: 1700285582
Provider Name (Legal Business Name): SHANNON CARLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 RIVERBEND DR
SPRINGFIELD OR
97477-8800
US

IV. Provider business mailing address

1115 SE 164TH AVE DEPT 358
VANCOUVER WA
98683-8004
US

V. Phone/Fax

Practice location:
  • Phone: 541-484-4332
  • Fax: 541-302-0786
Mailing address:
  • Phone: 360-729-1459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberARNP 9380645
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number201703390NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: