Healthcare Provider Details

I. General information

NPI: 1902641012
Provider Name (Legal Business Name): SHAILEE KOTHARI REGISTERED DIETITIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2024
Last Update Date: 06/29/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2116 4TH AVE UNIT 2215
SEATTLE WA
98121-2308
US

IV. Provider business mailing address

2116 4TH AVE UNIT 2215
SEATTLE WA
98121-2308
US

V. Phone/Fax

Practice location:
  • Phone: 564-654-3901
  • Fax:
Mailing address:
  • Phone: 564-654-3901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86359171
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: