Provider Demographics
NPI:1821851239
Name:SHINE PEDIATRICS, PLLC
Entity Type:Organization
Organization Name:SHINE PEDIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER, ARNP
Authorized Official - Prefix:
Authorized Official - First Name:STACI
Authorized Official - Middle Name:
Authorized Official - Last Name:SWAN
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:225-715-5242
Mailing Address - Street 1:25676 SE 149TH ST
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-8331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 116TH AVE NE STE 304
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3057
Practice Address - Country:US
Practice Address - Phone:225-715-5242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-31
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty