Provider Demographics
NPI:1073099875
Name:SACKETT, SHAWTA (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:SHAWTA
Middle Name:
Last Name:SACKETT
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 S COOLIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1893
Mailing Address - Country:US
Mailing Address - Phone:509-765-0674
Mailing Address - Fax:
Practice Address - Street 1:605 S COOLIDGE ST
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837
Practice Address - Country:US
Practice Address - Phone:509-765-0674
Practice Address - Fax:509-764-0344
Is Sole Proprietor?:No
Enumeration Date:2018-07-14
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60867849363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health