Provider Demographics
NPI:1073302352
Name:FITZGERALD, SHANNON K
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:K
Last Name:FITZGERALD
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1793 NW KEARNEY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2321
Mailing Address - Country:US
Mailing Address - Phone:650-387-1712
Mailing Address - Fax:
Practice Address - Street 1:1793 NW KEARNEY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2321
Practice Address - Country:US
Practice Address - Phone:650-387-1712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-03
Last Update Date:2025-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer