Provider Demographics
NPI:1962798793
Name:CLARK, SHAWNA A (DNP, FNP)
Entity type:Individual
Prefix:
First Name:SHAWNA
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:DNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 S CANYON BLVD
Mailing Address - Street 2:
Mailing Address - City:JOHN DAY
Mailing Address - State:OR
Mailing Address - Zip Code:97845-1044
Mailing Address - Country:US
Mailing Address - Phone:541-575-1263
Mailing Address - Fax:
Practice Address - Street 1:235 S CANYON BLVD
Practice Address - Street 2:
Practice Address - City:JOHN DAY
Practice Address - State:OR
Practice Address - Zip Code:97845-1044
Practice Address - Country:US
Practice Address - Phone:541-575-1263
Practice Address - Fax:541-575-0233
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1068A363LF0000X
OR201150064NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500640329Medicaid
ORR160652Medicare PIN