Provider Demographics
NPI:1457719304
Name:TANTAU, SHELLEY (ACNP)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:TANTAU
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9426 SW 268TH ST
Mailing Address - Street 2:
Mailing Address - City:VASHON
Mailing Address - State:WA
Mailing Address - Zip Code:98070-8416
Mailing Address - Country:US
Mailing Address - Phone:707-758-7700
Mailing Address - Fax:
Practice Address - Street 1:9426 SW 268TH ST
Practice Address - Street 2:
Practice Address - City:VASHON
Practice Address - State:WA
Practice Address - Zip Code:98070-8416
Practice Address - Country:US
Practice Address - Phone:707-758-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-07
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003458363LA2100X
WAAP60961397363LA2100X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2206062Medicaid
WA452330OtherLABOR & INDUSTRIES