Healthcare Provider Details

I. General information

NPI: 1114096294
Provider Name (Legal Business Name): JODY BYRNE DI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 11/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 HOYT AVE
EVERETT WA
98201-4918
US

IV. Provider business mailing address

3901 HOYT AVE
EVERETT WA
98201-4918
US

V. Phone/Fax

Practice location:
  • Phone: 425-339-5433
  • Fax:
Mailing address:
  • Phone: 425-339-5433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberDI00000405
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI00000405
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: