Provider Demographics
NPI:1871576876
Name:NORMAN, SHELLY JEANNE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:JEANNE
Last Name:NORMAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 MINES RD
Mailing Address - Street 2:
Mailing Address - City:WINLOCK
Mailing Address - State:WA
Mailing Address - Zip Code:98596-9539
Mailing Address - Country:US
Mailing Address - Phone:360-520-4795
Mailing Address - Fax:
Practice Address - Street 1:1270 SW WILLIAM AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-4730
Practice Address - Country:US
Practice Address - Phone:360-748-8814
Practice Address - Fax:925-364-2279
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2015-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005011363LF0000X, 363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9623976Medicaid