Healthcare Provider Details

I. General information

NPI: 1316364045
Provider Name (Legal Business Name): CRYSTAL CIMIC DI60446487
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2014
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8915 14TH AVE S
SEATTLE WA
98108-4813
US

IV. Provider business mailing address

PO BOX 34703
SEATTLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 206-788-3371
  • Fax:
Mailing address:
  • Phone: 206-764-3335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI60446487
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: