Basic Information
| Provider Information | |||||||||
| NPI: | 1639789795 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHATCOTT | ||||||||
| FirstName: | TISHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 251 | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838390251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085129028 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1000 E ELEP AVE | ||||||||
| Address2: | |||||||||
| City: | COLVILLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 991145014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096842573 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2020 | ||||||||
| LastUpdateDate: | 08/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | D-497 | ID | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.