Provider Demographics
NPI:1316759020
Name:LATENDRESSE, SHANNON LEIGH (RN)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEIGH
Last Name:LATENDRESSE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 NW 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-9300
Mailing Address - Country:US
Mailing Address - Phone:202-809-0532
Mailing Address - Fax:
Practice Address - Street 1:2213 NW 23RD AVE
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-9300
Practice Address - Country:US
Practice Address - Phone:202-809-0532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60321930163W00000X
WARN60321931163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163W00000XNursing Service ProvidersRegistered Nurse