Healthcare Provider Details

I. General information

NPI: 1407966476
Provider Name (Legal Business Name): VIRGINIA O'KELLY RD CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 03/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 ORONDO AVE SUITE 1
WENATCHEE WA
98801-2800
US

IV. Provider business mailing address

1105 FULLER ST
WENATCHEE WA
98801-3303
US

V. Phone/Fax

Practice location:
  • Phone: 509-662-6000
  • Fax: 509-664-4590
Mailing address:
  • Phone: 509-663-1708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberD100000141
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: