Basic Information
Provider Information | |||||||||
NPI: | 1780110775 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCGARY | ||||||||
FirstName: | AUDREY | ||||||||
MiddleName: | ANNA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RD, CD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DICKERSON | ||||||||
OtherFirstName: | AUDREY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 520 N 4TH AVE | ||||||||
Address2: |   | ||||||||
City: | PASCO | ||||||||
State: | WA | ||||||||
PostalCode: | 993015257 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5095477704 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 520 N 4TH AVE | ||||||||
Address2: |   | ||||||||
City: | PASCO | ||||||||
State: | WA | ||||||||
PostalCode: | 993015257 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5095477704 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2017 | ||||||||
LastUpdateDate: | 05/11/2017 | ||||||||
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 | 86031294 | WA | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
ID Information
ID | Type | State | Issuer | Description | DI 60756031 | 01 | WA | DIETITIAN CERTIFICATION | OTHER |