Provider Demographics
NPI:1578818662
Name:FULL LIFE NUTRITION
Entity Type:Organization
Organization Name:FULL LIFE NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:206-391-5479
Mailing Address - Street 1:5400 CALIFORNIA AVE SW
Mailing Address - Street 2:SUITE C
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98136-1501
Mailing Address - Country:US
Mailing Address - Phone:206-391-5479
Mailing Address - Fax:206-641-9702
Practice Address - Street 1:5400 CALIFORNIA AVE SW
Practice Address - Street 2:SUITE C
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98136-1501
Practice Address - Country:US
Practice Address - Phone:206-391-5479
Practice Address - Fax:206-641-9702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-16
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA01067726133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty