Healthcare Provider Details

I. General information

NPI: 1992900518
Provider Name (Legal Business Name): SHANNON DORAN FENSTER CN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11801 NE 158TH ST
BOTHELL WA
98011-4138
US

IV. Provider business mailing address

11801 NE 158TH ST
BOTHELL WA
98011-4138
US

V. Phone/Fax

Practice location:
  • Phone: 206-491-3008
  • Fax:
Mailing address:
  • Phone: 206-491-3008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberNU00001751
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberNU00001751
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: