Healthcare Provider Details

I. General information

NPI: 1285461517
Provider Name (Legal Business Name): AMBILY G KUSHAL RD CDR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 DEXTER AVE N UNIT B1030
SEATTLE WA
98109-4858
US

IV. Provider business mailing address

1305 DEXTER AVE N UNIT B1030
SEATTLE WA
98109-4858
US

V. Phone/Fax

Practice location:
  • Phone: 206-847-4125
  • Fax:
Mailing address:
  • Phone: 206-847-4125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.011934
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number859323
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDIET.DI.61633688
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number859323
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: