Healthcare Provider Details

I. General information

NPI: 1619422193
Provider Name (Legal Business Name): NICOLE PERIGARD RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE STEVENS RD

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 08/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8801 14TH AVE S
SEATTLE WA
98108-4809
US

IV. Provider business mailing address

PO BOX 34703
SEATTLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 206-764-0502
  • Fax: 206-764-0516
Mailing address:
  • Phone: 206-764-0502
  • Fax: 206-764-0516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1049396
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: