Healthcare Provider Details

I. General information

NPI: 1770420531
Provider Name (Legal Business Name): SHASTA LEE CARLSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8202 N DIVISION ST
SPOKANE WA
99208-5713
US

IV. Provider business mailing address

612 E BALLARD RD
COLBERT WA
99005-8516
US

V. Phone/Fax

Practice location:
  • Phone: 509-603-3335
  • Fax:
Mailing address:
  • Phone: 509-603-3335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN60993350
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: