Basic Information
| Provider Information | |||||||||
| NPI: | 1578617049 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLFF | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD CD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRUNSSEN | ||||||||
| OtherFirstName: | KATIE | ||||||||
| OtherMiddleName: | JEAN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 171 WILLOWLAWN RD | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095758101 | ||||||||
| FaxNumber: | 5095775011 | ||||||||
| Practice Location | |||||||||
| Address1: | 2811 TIETON DRIVE | ||||||||
| Address2: | YAKIMA VALLEY MEMORIAL HOSPITAL | ||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095758000 | ||||||||
| FaxNumber: | 5095775011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DI00001858 | WA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 8462392 | 05 | WA | MEDICAID |