Provider Demographics
NPI:1144251422
Name:RICHARDS, SHANNON KRISTINE (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:KRISTINE
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:KRISTINE
Other - Last Name:RANDLEMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:64-1032 MAMALAHOA HWY STE 306
Mailing Address - Street 2:
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-8441
Mailing Address - Country:US
Mailing Address - Phone:808-769-5010
Mailing Address - Fax:808-829-3603
Practice Address - Street 1:64-1032 MAMALAHOA HWY STE 306
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-8441
Practice Address - Country:US
Practice Address - Phone:808-769-5010
Practice Address - Fax:808-829-3603
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20085013NP363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORJ6956-01OtherPACIFICSOURCE
WA0189089Medicaid
WA9628181Medicaid
OR165242Medicaid