Provider Demographics
NPI:1215417704
Name:DIBBLE, JOHANNA NICOLE (RD)
Entity Type:Individual
Prefix:MISS
First Name:JOHANNA
Middle Name:NICOLE
Last Name:DIBBLE
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 1:1110 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-4920
Mailing Address - Country:US
Mailing Address - Phone:775-842-5400
Mailing Address - Fax:
Practice Address - Street 1:4030 ALDERWOOD MALL BLVD
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-6763
Practice Address - Country:US
Practice Address - Phone:425-776-0803
Practice Address - Fax:425-776-0813
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86065807133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered