Provider Demographics
NPI:1235604935
Name:ST JOHN, BRENNA
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:
Last Name:ST JOHN
Suffix:
Gender:F
Credentials:
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 1081
Mailing Address - Street 2:
Mailing Address - City:TEKOA
Mailing Address - State:WA
Mailing Address - Zip Code:99033-1081
Mailing Address - Country:US
Mailing Address - Phone:509-710-1286
Mailing Address - Fax:
Practice Address - Street 1:1200 W FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:COLFAX
Practice Address - State:WA
Practice Address - Zip Code:99111-9552
Practice Address - Country:US
Practice Address - Phone:509-397-5743
Practice Address - Fax:509-397-5763
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60898597133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered