Healthcare Provider Details

I. General information

NPI: 1083006522
Provider Name (Legal Business Name): SHANNON ELOISE BOLT ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON ELOISE REIS

II. Dates (important events)

Enumeration Date: 02/20/2015
Last Update Date: 11/21/2022
Certification Date: 11/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4209 TIETON DR
YAKIMA WA
98908-3377
US

IV. Provider business mailing address

4209 TIETON DR
YAKIMA WA
98908-3377
US

V. Phone/Fax

Practice location:
  • Phone: 509-654-9810
  • Fax: 509-966-8812
Mailing address:
  • Phone: 509-654-9810
  • Fax: 509-966-8812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61369683
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60528267
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: