Healthcare Provider Details

I. General information

NPI: 1881496826
Provider Name (Legal Business Name): SHADHI NICOLE MANSOORI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2025
Last Update Date: 04/12/2025
Certification Date: 04/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 NORTH 115TH STREET BOX 358828
SEATTLE WA
98133
US

IV. Provider business mailing address

1550 NORTH 115TH STREET BOX 358828
SEATTLE WA
98133
US

V. Phone/Fax

Practice location:
  • Phone: 206-543-6577
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: