Provider Demographics
NPI:1992519060
Name:ELLISON, SHAUNA (ABOC)
Entity type:Individual
Prefix:
First Name:SHAUNA
Middle Name:
Last Name:ELLISON
Suffix:
Gender:F
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2375 NE HIGHWAY 99W
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-9201
Mailing Address - Country:US
Mailing Address - Phone:503-434-1183
Mailing Address - Fax:
Practice Address - Street 1:2375 NE HIGHWAY 99W
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-9201
Practice Address - Country:US
Practice Address - Phone:503-434-1183
Practice Address - Fax:503-472-7433
Is Sole Proprietor?:No
Enumeration Date:2025-02-06
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ228441156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician