Healthcare Provider Details

I. General information

NPI: 1558480749
Provider Name (Legal Business Name): DANA MARIE SHEPHERD ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DANA MARIE SMITH ARNP

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 04/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 COOKS HILL RD
CENTRALIA WA
98531-9073
US

IV. Provider business mailing address

1911 COOKS HILL RD
CENTRALIA WA
98531-9073
US

V. Phone/Fax

Practice location:
  • Phone: 360-736-6778
  • Fax: 360-736-6552
Mailing address:
  • Phone: 360-736-6778
  • Fax: 360-736-6552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN00145561
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP30006273
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: