Healthcare Provider Details

I. General information

NPI: 1568186203
Provider Name (Legal Business Name): IAN WASHINGTON RD/RDN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2022
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

3802 MCREE AVE APT 2E
SAINT LOUIS MO
63110-2659
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5600
  • Fax:
Mailing address:
  • Phone: 417-372-7151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number2022030219
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: