Healthcare Provider Details

I. General information

NPI: 1679714281
Provider Name (Legal Business Name): JAN KINCAID RYSTROM R.D., C.D.E.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2009
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 COLUMBIA ST STE 400
SEATTLE WA
98104-2053
US

IV. Provider business mailing address

PO BOX 25608
SALT LAKE CITY UT
84125-0608
US

V. Phone/Fax

Practice location:
  • Phone: 206-215-2440
  • Fax: 206-215-2457
Mailing address:
  • Phone: 206-320-4476
  • Fax: 206-568-7043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI60098525
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: