Provider Demographics
NPI:1992566806
Name:EASTIN, SHELBY MARIE (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:SHELBY
Middle Name:MARIE
Last Name:EASTIN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:M
Other - Last Name:BURROUGHS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6044 YOSEMITE DR
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-2005
Mailing Address - Country:US
Mailing Address - Phone:618-335-1536
Mailing Address - Fax:
Practice Address - Street 1:11311 BRIDGEPORT WAY SW STE 207
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3051
Practice Address - Country:US
Practice Address - Phone:253-272-8664
Practice Address - Fax:253-627-7880
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61526448363LA2200X, 363LF0000X
IN28251063C363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2280338Medicaid