Healthcare Provider Details

I. General information

NPI: 1811394935
Provider Name (Legal Business Name): PHILLIP LUTHER SHEALY ARNP, FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 SW 16TH ST. STE. 121
RENTON WA
98057-2628
US

IV. Provider business mailing address

23745 225TH WAY SE STE 201
MAPLE VALLEY WA
98038-5294
US

V. Phone/Fax

Practice location:
  • Phone: 206-805-8885
  • Fax: 206-805-8886
Mailing address:
  • Phone: 803-943-8358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60508185
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: