Provider Demographics
NPI:1124502190
Name:MABIE, SHANNON LEANN (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LEANN
Last Name:MABIE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2875 NE STUCKI AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-5806
Mailing Address - Country:US
Mailing Address - Phone:951-756-5642
Mailing Address - Fax:
Practice Address - Street 1:255 TERRACINA BLVD STE 202
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4870
Practice Address - Country:US
Practice Address - Phone:909-748-6065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010011363LF0000X
OR202200229NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily