Basic Information
Provider Information | |||||||||
NPI: | 1215569009 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELIZAGA | ||||||||
FirstName: | SHELBY | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP, DNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ORNDOFF | ||||||||
OtherFirstName: | SHELBY | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | ARNP, DNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 50095 | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981455095 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2065205700 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1959 NE PACIFIC ST | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981952420 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2065205000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/10/2020 | ||||||||
LastUpdateDate: | 01/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/03/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0200X | RN60425195 | WA | N |   | Nursing Service Providers | Registered Nurse | Critical Care Medicine | 363L00000X | AP61228632 | WA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LA2100X | AP61228632 | WA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
ID | Type | State | Issuer | Description | 1215569009 | 05 | WA |   | MEDICAID |