1467987537 NPI number — SHIRLEY MATENDA RD

Table of content: SHIRLEY MATENDA RD (NPI 1467987537)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467987537 NPI number — SHIRLEY MATENDA RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATENDA
Provider First Name:
SHIRLEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WASSWA-KINTU
Provider Other First Name:
SHIRLEY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RDN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467987537
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 BROADWAY E , SEATTLE, WA
Provider Second Line Business Mailing Address:
PMB #228
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-395-4819
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16045 1ST AVE S FL 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURIEN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98148-1401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-965-4100
Provider Business Practice Location Address Fax Number:
206-965-4278
Provider Enumeration Date:
04/26/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133NN1002X , with the licence number:  DI60727023 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133VN1006X , with the licence number: DI60727023 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X , with the licence number: DI60727023 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2079868 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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