Basic Information
| Provider Information | |||||||||
| NPI: | 1447361258 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JONATHAN WAINRIGHT VA MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1223 SE DEWEY DR | ||||||||
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| City: | COLLEGE PLACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993241846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095251253 | ||||||||
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| Practice Location | |||||||||
| Address1: | 77 WAINWRIGHT DR | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993623975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095255200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 06/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | WALIKONIS | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
| AuthorizedOfficialMiddleName: | SUE | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL DIETITIAN | ||||||||
| AuthorizedOfficialTelephone: | 5095255200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | R.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 552547 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.