Provider Demographics
NPI:1861137275
Name:MOON, SHANNA (MSCN)
Entity type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:MSCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6576 SW FIRLOCK WAY APT 8
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-7986
Mailing Address - Country:US
Mailing Address - Phone:478-396-6572
Mailing Address - Fax:
Practice Address - Street 1:6576 SW FIRLOCK WAY APT 8
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-7986
Practice Address - Country:US
Practice Address - Phone:478-396-6572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist