Healthcare Provider Details

I. General information

NPI: 1558182329
Provider Name (Legal Business Name): DEBORAH LUXEM RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S 43RD ST
RENTON WA
98055-5714
US

IV. Provider business mailing address

400 S 43RD ST
RENTON WA
98055-5714
US

V. Phone/Fax

Practice location:
  • Phone: 425-228-3440
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1043772
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: