Healthcare Provider Details

I. General information

NPI: 1942622170
Provider Name (Legal Business Name): NICOLE OPSTAD RD, CD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2014
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 W 8TH AVE
KENNEWICK WA
99336-5630
US

IV. Provider business mailing address

203 W 8TH AVE PO BOX 6128
KENNEWICK WA
99336-5630
US

V. Phone/Fax

Practice location:
  • Phone: 509-378-7792
  • Fax: 509-586-5140
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1104941
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: