Provider Demographics
NPI:1235530528
Name:BUCCOLA, EMILY (RD)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:BUCCOLA
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 1:5331 SW MACADAM AVE
Mailing Address - Street 2:SUITE 258, PMB #535
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-6104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8050 SE 13TH AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-6694
Practice Address - Country:US
Practice Address - Phone:562-256-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-06
Last Update Date:2014-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1080021133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered