Provider Demographics
NPI:1235892167
Name:RASTETTER, SHANNON KELLY (RN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:KELLY
Last Name:RASTETTER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13606 231ST PL SE
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-8455
Mailing Address - Country:US
Mailing Address - Phone:206-660-5602
Mailing Address - Fax:
Practice Address - Street 1:160 NW GILMAN BLVD STE 406
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2549
Practice Address - Country:US
Practice Address - Phone:206-523-1212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60179026163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAOTHEROtherN/A