MEDICARE: BRIDGET ANN NICHOLS RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	01067726	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DI 60337149	OTHER	WA	WASHINGTON STATE DEPARTMENT OF HEALTH

General Provider Information

NPI Number	:	1356622922
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIDGET ANN NICHOLS RD

Provider Business Mailing Address
First Line	:	5016 CALIFORNIA AVE SW APT 401
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98136-1281
Country	:	US
Telephone Number	:	206-391-5479
Fax Number	:

Provider Business Practice Location Address
First Line	:	5400 CALIFORNIA AVE SW STE C
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98136-1501
Country	:	US
Telephone Number	:	206-391-5479
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2011
Last Update Date	:	04/11/2013

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