Provider Demographics
NPI:1508952748
Name:BASTIAN, DENAE R (RD)
Entity Type:Individual
Prefix:
First Name:DENAE
Middle Name:R
Last Name:BASTIAN
Suffix:
Gender:F
Credentials:RD
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 1166
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-1166
Mailing Address - Country:US
Mailing Address - Phone:425-258-7357
Mailing Address - Fax:425-258-7022
Practice Address - Street 1:900 PACIFIC AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4168
Practice Address - Country:US
Practice Address - Phone:425-258-7311
Practice Address - Fax:425-258-7618
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001618133V00000X, 133N00000X, 133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Not Answered133N00000XDietary & Nutritional Service ProvidersNutritionist
Not Answered133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8429615Medicaid
WA9956596Medicare ID - Type Unspecified