Healthcare Provider Details

I. General information

NPI: 1013420124
Provider Name (Legal Business Name): SHANNON KRISTINE URBAN ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2017
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16811 SE MCGILLIVRAY BLVD
VANCOUVER WA
98683-3404
US

IV. Provider business mailing address

5116 NASSAU CT NE
TACOMA WA
98422-4528
US

V. Phone/Fax

Practice location:
  • Phone: 360-735-8100
  • Fax:
Mailing address:
  • Phone: 253-223-8842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60810810
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: