Provider Demographics
NPI:1366901613
Name:AUSTIN, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25250 SW MEADOWBROOK LN
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-8493
Mailing Address - Country:US
Mailing Address - Phone:503-502-1262
Mailing Address - Fax:
Practice Address - Street 1:25250 SW MEADOWBROOK LN
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-8493
Practice Address - Country:US
Practice Address - Phone:503-502-1262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-17
Last Update Date:2019-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education