Provider Demographics
NPI:1770959025
Name:HERZOG, SHANTI ELIZABETH (FNP)
Entity type:Individual
Prefix:
First Name:SHANTI
Middle Name:ELIZABETH
Last Name:HERZOG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2101 E YESLER WAY
Mailing Address - Street 2:STE 210
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-5959
Mailing Address - Country:US
Mailing Address - Phone:503-988-7468
Mailing Address - Fax:503-988-3015
Practice Address - Street 1:6334 LITTLEROCK RD SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-7332
Practice Address - Country:US
Practice Address - Phone:360-704-7590
Practice Address - Fax:360-704-7591
Is Sole Proprietor?:No
Enumeration Date:2015-08-20
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAAP60791095363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR22959Medicaid
OR096511Medicaid
ORR0000WCJHTMedicare Oscar/Certification