Healthcare Provider Details

I. General information

NPI: 1699495929
Provider Name (Legal Business Name): KEONDRA MARTINIQUE RUSTAN PMHNP-DNP, PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 S LANE ST
SEATTLE WA
98144-2810
US

IV. Provider business mailing address

3116 164TH ST SW APT 1406
LYNNWOOD WA
98087-3250
US

V. Phone/Fax

Practice location:
  • Phone: 206-682-2371
  • Fax:
Mailing address:
  • Phone: 760-895-5514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberARNP.AP.70007587-NP
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: