Provider Demographics
NPI:1336484864
Name:BALLEJOS, MIRIAM SARA (PHD, RD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:SARA
Last Name:BALLEJOS
Suffix:
Gender:F
Credentials:PHD, RD
Other - Prefix:
Other - First Name:MIRIAM
Other - Middle Name:SARA
Other - Last Name:EDLEFSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD, RD
Mailing Address - Street 1:9040A JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:253-968-0547
Mailing Address - Fax:
Practice Address - Street 1:9040A JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431
Practice Address - Country:US
Practice Address - Phone:253-968-0547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-10
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60224467133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered