Provider Demographics
NPI:1063670701
Name:GOODWIN, MALVINA ANN (RD CD)
Entity Type:Individual
Prefix:
First Name:MALVINA
Middle Name:ANN
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:RD CD
Other - Prefix:
Other - First Name:ANNIE
Other - Middle Name:
Other - Last Name:GOODWIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD CD
Mailing Address - Street 1:7102 W OKANOGAN PLACE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336
Mailing Address - Country:US
Mailing Address - Phone:509-460-4246
Mailing Address - Fax:509-585-1525
Practice Address - Street 1:7102 W OKANOGAN PLACE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336
Practice Address - Country:US
Practice Address - Phone:509-460-4246
Practice Address - Fax:509-585-1525
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
579458133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8267387Medicaid