Provider Demographics
NPI:1003067133
Name:ELLEFSEN, LILE D (RD)
Entity Type:Individual
Prefix:
First Name:LILE
Middle Name:D
Last Name:ELLEFSEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12906 NE 128TH PL
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-7901
Mailing Address - Country:US
Mailing Address - Phone:425-823-7764
Mailing Address - Fax:
Practice Address - Street 1:13008 NE 125TH WAY
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-7726
Practice Address - Country:US
Practice Address - Phone:425-814-8443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000922133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered