Provider Demographics
NPI:1124519822
Name:EATON, SHANNON MICHELLE (MSN, FPMHNP, PMHNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MICHELLE
Last Name:EATON
Suffix:
Gender:F
Credentials:MSN, FPMHNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 W REPUBLIC RD STE 108
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5816
Mailing Address - Country:US
Mailing Address - Phone:425-678-3582
Mailing Address - Fax:417-356-8800
Practice Address - Street 1:535 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4142
Practice Address - Country:US
Practice Address - Phone:503-755-6703
Practice Address - Fax:503-755-6704
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO138149163W00000X
MO2018024368363LP0808X
WAAP61106759363LP0808X
OR10027243363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420056428Medicaid