Healthcare Provider Details

I. General information

NPI: 1215419494
Provider Name (Legal Business Name): LOIS GAUTAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 SAND POINT WAY NE
SEATTLE WA
98105-3901
US

IV. Provider business mailing address

10203 18TH AVE SW
SEATTLE WA
98146-1315
US

V. Phone/Fax

Practice location:
  • Phone: 206-987-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLDD10219556
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI60524624
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: