Provider Demographics
NPI:1669595237
Name:GWARTNEY, SHANNON MARIE (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:GWARTNEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 SW 15TH AVE.
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205
Mailing Address - Country:US
Mailing Address - Phone:503-274-4994
Mailing Address - Fax:503-243-5849
Practice Address - Street 1:808 SW 15TH AVE.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205
Practice Address - Country:US
Practice Address - Phone:503-274-4994
Practice Address - Fax:503-243-5849
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200250121NP363LA2200X
OR200150082NP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health