Healthcare Provider Details

I. General information

NPI: 1366456832
Provider Name (Legal Business Name): SUSAN LEE SHANE ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 06/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 FOUNDERS WAY SUITE 1
FORKS WA
98331-9062
US

IV. Provider business mailing address

PO BOX 153 411 CALAWAH
FORKS WA
98331-0153
US

V. Phone/Fax

Practice location:
  • Phone: 360-374-9180
  • Fax: 360-374-3162
Mailing address:
  • Phone: 360-374-9180
  • Fax: 360-374-3162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License NumberRN00050684
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code364SW0102X
TaxonomyWomen's Health Clinical Nurse Specialist
License NumberAP30000331
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: