Provider Demographics
NPI:1508257163
Name:WAISBAUM, ROMINA P (1003092)
Entity Type:Individual
Prefix:
First Name:ROMINA
Middle Name:P
Last Name:WAISBAUM
Suffix:
Gender:F
Credentials:1003092
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 BELLEVUE WAY NE # S233
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-2327
Mailing Address - Country:US
Mailing Address - Phone:404-704-6674
Mailing Address - Fax:
Practice Address - Street 1:250 BELLEVUE WAY NE # S233
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-2327
Practice Address - Country:US
Practice Address - Phone:404-704-6674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1003092133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal