Healthcare Provider Details

I. General information

NPI: 1801129689
Provider Name (Legal Business Name): MICHEL LEIGH BERNOTAS R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 06/18/2020
Certification Date: 06/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22842 NE 42ND ST
REDMOND WA
98053-8322
US

IV. Provider business mailing address

22842 NE 42ND ST
REDMOND WA
98053-8322
US

V. Phone/Fax

Practice location:
  • Phone: 651-785-5289
  • Fax:
Mailing address:
  • Phone: 651-785-5289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: