Provider Demographics
NPI:1871205708
Name:SMITH, SHANNA NICOLE (CRM,PWS)
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CRM,PWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 S EMPIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-3374
Mailing Address - Country:US
Mailing Address - Phone:541-256-4635
Mailing Address - Fax:
Practice Address - Street 1:155 S EMPIRE BLVD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-3374
Practice Address - Country:US
Practice Address - Phone:541-256-4635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-22
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORTHW000107728OtherTRADITIONAL HEALTHCARE WORKER