Provider Demographics
NPI:1841098753
Name:ISLAND NUTRITION, PLLC
Entity type:Organization
Organization Name:ISLAND NUTRITION, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUBE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RDN, CD
Authorized Official - Phone:360-544-2466
Mailing Address - Street 1:418 SW JUDSON DR
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-5802
Mailing Address - Country:US
Mailing Address - Phone:360-544-2466
Mailing Address - Fax:360-873-0017
Practice Address - Street 1:720 SE PIONEER WAY
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-5752
Practice Address - Country:US
Practice Address - Phone:360-544-2466
Practice Address - Fax:360-873-0017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2279837Medicaid