Individual
SHANNON ELIZABETH WIEDEMAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP AND RN
Contact information
Practice address
207 SW 1ST ST, ENTERPRISE, OR 97828-1203
(541) 426-0801
(541) 426-0802
Mailing address
207 SW 1ST ST, ENTERPRISE, OR 97828-1203
(541) 426-4524
(541) 426-3035
Taxonomy
Speciality
Code
Description
License number
State
163WP0808X
Psychiatric/Mental Health Registered Nurse
Primary
201043506RN
OR
363LA2200X
Adult Health Nurse Practitioner
201050225NP
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
383864
MEDICARE RHC
OR
05
—
500641038
—
OR
01
—
O10244476AA
REGENCE BLUE CROSS BLUE SHIELD
OR
Enumeration date
07/25/2008
Last updated
04/05/2016
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