Provider Demographics
NPI:1497984108
Name:MIZE, CHARLENE K (MS, RDN, CD)
Entity Type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:K
Last Name:MIZE
Suffix:
Gender:F
Credentials:MS, RDN, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 S 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3521
Mailing Address - Country:US
Mailing Address - Phone:509-249-5345
Mailing Address - Fax:509-249-5265
Practice Address - Street 1:302 S 10TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3521
Practice Address - Country:US
Practice Address - Phone:509-249-5345
Practice Address - Fax:509-249-5265
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60131546133V00000X, 133V00000X
WA984556133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2057584Medicaid
WAG8951718Medicare PIN
WA2057584Medicaid