Basic Information
Provider Information | |||||||||
NPI: | 1154780658 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BENNETT | ||||||||
FirstName: | STEFANIE | ||||||||
MiddleName: | QUINN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S., R.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 820 N CHELAN AVE | ||||||||
Address2: |   | ||||||||
City: | WENATCHEE | ||||||||
State: | WA | ||||||||
PostalCode: | 988012028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5096638711 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1201 S MILLER ST | ||||||||
Address2: |   | ||||||||
City: | WENATCHEE | ||||||||
State: | WA | ||||||||
PostalCode: | 988013201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5096621511 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/12/2016 | ||||||||
LastUpdateDate: | 08/08/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DI60610909 | WA | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
ID Information
ID | Type | State | Issuer | Description | 1154780658 | 05 | WA |   | MEDICAID | P01674680 | 01 | WA | RR PTAN WVH | OTHER |