Healthcare Provider Details

I. General information

NPI: 1316366859
Provider Name (Legal Business Name): DIANA CHISLETT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 04/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 114TH AVE SE #180
BELLEVUE WA
98004-6950
US

IV. Provider business mailing address

1601 114TH AVE SE #180
BELLEVUE WA
98004-6950
US

V. Phone/Fax

Practice location:
  • Phone: 425-451-1134
  • Fax: 425-451-8501
Mailing address:
  • Phone: 425-451-1134
  • Fax: 425-451-8501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI60303384
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: