Healthcare Provider Details

I. General information

NPI: 1023125424
Provider Name (Legal Business Name): SHANNA LEE ANGEL ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANNA LEE HADLOCK

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 ADAMS
MORTON WA
98356
US

IV. Provider business mailing address

PO BOX 508
MOSSYROCK WA
98564-0508
US

V. Phone/Fax

Practice location:
  • Phone: 360-496-5112
  • Fax: 360-496-3511
Mailing address:
  • Phone: 360-496-3702
  • Fax: 496-983-3098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP30005616
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: