Provider Demographics
NPI:1154602746
Name:RYAN, SHANNON C (PMHNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:C
Last Name:RYAN
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 OAK ST
Mailing Address - Street 2:STE 205
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-2542
Mailing Address - Country:US
Mailing Address - Phone:541-727-7787
Mailing Address - Fax:541-727-7529
Practice Address - Street 1:312 OAK ST
Practice Address - Street 2:STE 205
Practice Address - City:CENTRAL POINT
Practice Address - State:OR
Practice Address - Zip Code:97502-2542
Practice Address - Country:US
Practice Address - Phone:541-727-7787
Practice Address - Fax:541-727-7529
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-08
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR099000570RN163WC1500X
OR201600527NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR163WC1500XMedicaid
OR16Medicaid