Provider Demographics
NPI:1245608512
Name:OBERLIN, BREANNA (MS, RD, CD, CDE)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:OBERLIN
Suffix:
Gender:F
Credentials:MS, RD, CD, CDE
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 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-215-2440
Mailing Address - Fax:
Practice Address - Street 1:801 BROADWAY
Practice Address - Street 2:611
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-4396
Practice Address - Country:US
Practice Address - Phone:205-215-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-03
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60174557133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered