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NPI Code Detail

MEDICARE: REVONNA SHANTAY KING

MEDICARE: REVONNA SHANTAY KING
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1164W00000XLicensed Practical NurseLP00036735WA

General Provider Information

NPI Number : 1174485874
Entity Type Code : Individual
Provider Name (Legal Business Name) : REVONNA SHANTAY KING
Provider Business Mailing Address
First Line : 2212 S JACKSON ST
Second Line :
City : SEATTLE
State : WA
Zip : 98144-2591
Country : US
Telephone Number : 206-322-2387
Fax Number :
Provider Business Practice Location Address
First Line : 2212 S JACKSON ST
Second Line :
City : SEATTLE
State : WA
Zip : 98144-2591
Country : US
Telephone Number : 206-322-2387
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/01/2025
Last Update Date : 12/01/2025

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Directions to “ REVONNA SHANTAY KING ” Practice Location

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These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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