Healthcare Provider Details

I. General information

NPI: 1730769266
Provider Name (Legal Business Name): CHERYL DAWN HAVENS RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 04/09/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7114 SW BOUCHAINE ST
WILSONVILLE OR
97070-8856
US

IV. Provider business mailing address

7114 SW BOUCHAINE ST
WILSONVILLE OR
97070-8856
US

V. Phone/Fax

Practice location:
  • Phone: 503-705-1610
  • Fax:
Mailing address:
  • Phone: 503-705-1610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-D10281170
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: