Healthcare Provider Details

I. General information

NPI: 1528152477
Provider Name (Legal Business Name): SUDHA NAGA NANDIGA RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 02/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 PACIFIC AVE FL 7
EVERETT WA
98201-4168
US

IV. Provider business mailing address

909 N BROADWAY PBO
EVERETT WA
98201-1409
US

V. Phone/Fax

Practice location:
  • Phone: 425-258-7459
  • Fax: 425-258-7579
Mailing address:
  • Phone: 425-317-0264
  • Fax: 425-317-0291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI00001750
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDI00001750
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberDI00001750
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: