Basic Information
| Provider Information | |||||||||
| NPI: | 1528454105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORD | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | RD, LD, CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4825 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608822778 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 700 NE 87TH AVE STE 280 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608822778 | ||||||||
| FaxNumber: | 3606041785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2015 | ||||||||
| LastUpdateDate: | 03/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | LD-D-000980 | OR | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133VN1004X | LD-D-000980 | OR | N | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric | 136A00000X | DI60925857 | WA | N | Dietary & Nutritional Service Providers | Dietetic Technician, Registered | 133V00000X | DI60925857 | WA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 2044150 | 05 | WA | MEDICAID |