Healthcare Provider Details

I. General information

NPI: 1770959025
Provider Name (Legal Business Name): SHANTI ELIZABETH HERZOG FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2015
Last Update Date: 12/11/2020
Certification Date: 12/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6334 LITTLEROCK RD SW
TUMWATER WA
98512-7332
US

IV. Provider business mailing address

2101 E YESLER WAY STE 210
SEATTLE WA
98122-5959
US

V. Phone/Fax

Practice location:
  • Phone: 360-704-7590
  • Fax: 360-704-7591
Mailing address:
  • Phone: 503-988-7468
  • Fax: 503-988-3015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60791095
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: