Healthcare Provider Details

I. General information

NPI: 1922474980
Provider Name (Legal Business Name): EMILY WALL MS, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2015
Last Update Date: 08/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4003 CREEKSIDE LOOP NUTRITION SERVICES
YAKIMA WA
98908-3962
US

IV. Provider business mailing address

2811 TIETON DR CLINICAL NUTRITION SERVICES
YAKIMA WA
98902-3761
US

V. Phone/Fax

Practice location:
  • Phone: 509-573-3875
  • Fax: 509-225-2711
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI60592163
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: