Provider Demographics
NPI:1285918938
Name:LEACH, SHANNON M (ARNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:M
Last Name:LEACH
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:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:1700 13TH ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1689
Practice Address - Country:US
Practice Address - Phone:425-404-5345
Practice Address - Fax:425-404-5330
Is Sole Proprietor?:No
Enumeration Date:2011-09-29
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60247426363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP60247426OtherWSL
WAAP60247426OtherWSL
WAG8938825Medicare UPIN