Provider Demographics
NPI:1760986160
Name:SHIVACHI, SALOME KHASUNGU (RN)
Entity Type:Individual
Prefix:MISS
First Name:SALOME
Middle Name:KHASUNGU
Last Name:SHIVACHI
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 1:208 TACOMA BLVD N
Mailing Address - Street 2:
Mailing Address - City:PACIFIC
Mailing Address - State:WA
Mailing Address - Zip Code:98047-1010
Mailing Address - Country:US
Mailing Address - Phone:205-356-5838
Mailing Address - Fax:
Practice Address - Street 1:208 TACOMA BLVD N
Practice Address - Street 2:
Practice Address - City:PACIFIC
Practice Address - State:WA
Practice Address - Zip Code:98047-1010
Practice Address - Country:US
Practice Address - Phone:205-356-5838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60618577163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAH2014Medicaid