Provider Demographics
NPI:1467987537
Name:MATENDA, SHIRLEY
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:MATENDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHIRLEY
Other - Middle Name:
Other - Last Name:WASSWA-KINTU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN
Mailing Address - Street 1:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-595-3822
Mailing Address - Fax:425-257-1423
Practice Address - Street 1:3901 HOYT AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4918
Practice Address - Country:US
Practice Address - Phone:425-595-3822
Practice Address - Fax:425-257-1423
Is Sole Proprietor?:No
Enumeration Date:2017-04-26
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60727023133NN1002X, 133VN1006X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic