Provider Demographics
NPI:1235796376
Name:BERRETTA, NICHOLAS ALBERT (RDN, CD)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:ALBERT
Last Name:BERRETTA
Suffix:
Gender:M
Credentials:RDN, CD
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 12242
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-0242
Mailing Address - Country:US
Mailing Address - Phone:509-528-5011
Mailing Address - Fax:425-949-5413
Practice Address - Street 1:10634 E RIVERSIDE DR STE 250
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3759
Practice Address - Country:US
Practice Address - Phone:425-949-7626
Practice Address - Fax:425-949-5413
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60863913133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1033254115Medicaid
WA1669938536Medicaid
WA1891802146Medicaid