Healthcare Provider Details

I. General information

NPI: 1235874975
Provider Name (Legal Business Name): SHANNON TILLERY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 N 41ST ST
SEATTLE WA
98103-7002
US

IV. Provider business mailing address

522 W RIVERSIDE AVE STE N
SPOKANE WA
99201-0581
US

V. Phone/Fax

Practice location:
  • Phone: 971-266-3096
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD70019274
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: