Provider Demographics
NPI:1013181643
Name:BELZER, PHYLLIS (REGISTERED DIETICIAN)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:BELZER
Suffix:
Gender:F
Credentials:REGISTERED DIETICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 197
Mailing Address - Street 2:500 E. WEBSTER
Mailing Address - City:CHEWELAH
Mailing Address - State:WA
Mailing Address - Zip Code:99109-0197
Mailing Address - Country:US
Mailing Address - Phone:509-935-5220
Mailing Address - Fax:
Practice Address - Street 1:500 E WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:CHEWELAH
Practice Address - State:WA
Practice Address - Zip Code:99109-9523
Practice Address - Country:US
Practice Address - Phone:509-935-5220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000317133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP72218Medicare UPIN