Basic Information
| Provider Information | |||||||||
| NPI: | 1982039475 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHELLEY | ||||||||
| FirstName: | DANAE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD, CDE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ZARBUCK | ||||||||
| OtherFirstName: | DANAE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8915 14TH AVE S | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981084813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067644700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3801 150TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980061668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254607140 | ||||||||
| FaxNumber: | 4254607161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2013 | ||||||||
| LastUpdateDate: | 06/25/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 164.005980 | IL | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | DI60563553 | WA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 164.005980 | 01 | IL | LICENSE # | OTHER |