1134373723 NPI number — MS. SHANNON KAELENE MRET CHT LMP

Table of content: BARBARA ANN PENN MA, MT-BC (NPI 1659634749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134373723 NPI number — MS. SHANNON KAELENE MRET CHT LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KAELENE
Provider First Name:
SHANNON
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MRET CHT LMP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134373723
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10883 SE 10TH ST
Provider Second Line Business Mailing Address:
G61
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98664-6154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-807-7217
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7604 NE 5TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98665-8204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-807-7217
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  MA00023591 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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