Basic Information
Provider Information | |||||||||
NPI: | 1912158239 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DACQUISTO | ||||||||
FirstName: | KARA | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SCHRANDT | ||||||||
OtherFirstName: | KARA | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 909 N BROADWAY | ||||||||
Address2: | PBO CREDENTIALING | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982011409 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4253170264 | ||||||||
FaxNumber: | 4253170291 | ||||||||
Practice Location | |||||||||
Address1: | 916 PACIFIC AVE | ||||||||
Address2: | SEVENTH FLOOR | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982014147 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4253036500 | ||||||||
FaxNumber: | 4253036550 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2008 | ||||||||
LastUpdateDate: | 01/30/2009 | ||||||||
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 | 133N00000X |   |   | N |   | Dietary & Nutritional Service Providers | Nutritionist |   | 133NN1002X |   |   | N |   | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education | 133V00000X |   |   | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   | 133VN1004X |   |   | N |   | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric |
ID Information
ID | Type | State | Issuer | Description | DI00001749 | 01 | WA | WA STATE LICENSE | OTHER |