Provider Demographics
NPI:1134809155
Name:SHADE, LAUREN EILEEN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:EILEEN
Last Name:SHADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 N 88TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-2131
Mailing Address - Country:US
Mailing Address - Phone:425-749-9511
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-0001
Practice Address - Country:US
Practice Address - Phone:425-749-9511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60918239163W00000X
WAAP61553983363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse