Healthcare Provider Details

I. General information

NPI: 1952502163
Provider Name (Legal Business Name): LYNN L KIDDER MPH, RD, CD, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12052 WILMINGTON WAY
MUKILTEO WA
98275-6018
US

IV. Provider business mailing address

12052 WILMINGTON WAY
MUKILTEO WA
98275-6018
US

V. Phone/Fax

Practice location:
  • Phone: 206-280-3367
  • Fax:
Mailing address:
  • Phone: 206-280-3367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: