Healthcare Provider Details

I. General information

NPI: 1306471867
Provider Name (Legal Business Name): SHANNON MICHELLE DEWALD ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2020
Last Update Date: 12/13/2022
Certification Date: 12/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4245 ROOSEVELT WAY NE FL 2
SEATTLE WA
98105-6008
US

IV. Provider business mailing address

PO BOX 50095
SEATTLE WA
98145-5095
US

V. Phone/Fax

Practice location:
  • Phone: 206-598-6285
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP61325865
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60641197
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: