Healthcare Provider Details

I. General information

NPI: 1063103554
Provider Name (Legal Business Name): SHANNON TRANTHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2023
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6409 E MILL PLAIN BLVD
VANCOUVER WA
98661-7454
US

IV. Provider business mailing address

4301 NW WASHINGTON ST
VANCOUVER WA
98660-1767
US

V. Phone/Fax

Practice location:
  • Phone: 360-718-8376
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: