MEDICARE: SHANNON KELLY RASTETTER RN

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
1	163WL0100X	Lactation Consultant (Registered Nurse)	RN60179026	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OTHER	OTHER	WA	N/A

General Provider Information

NPI Number	:	1235892167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON KELLY RASTETTER RN

Provider Business Mailing Address
First Line	:	13606 231ST PL SE
Second Line	:
City	:	ISSAQUAH
State	:	WA
Zip	:	98027-8455
Country	:	US
Telephone Number	:	206-660-5602
Fax Number	:

Provider Business Practice Location Address
First Line	:	160 NW GILMAN BLVD STE 406
Second Line	:
City	:	ISSAQUAH
State	:	WA
Zip	:	98027-2549
Country	:	US
Telephone Number	:	206-523-1212
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2021
Last Update Date	:	10/18/2021

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