Provider Demographics
NPI:1609994391
Name:COLLINS, BRENDA J (MSRD)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:J
Last Name:COLLINS
Suffix:
Gender:F
Credentials:MSRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2242
Mailing Address - Country:US
Mailing Address - Phone:509-248-6292
Mailing Address - Fax:509-248-9134
Practice Address - Street 1:315 HOLTON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3254
Practice Address - Country:US
Practice Address - Phone:509-248-6292
Practice Address - Fax:509-248-9134
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001934133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADI00001934OtherSTATE LICENSE
Q50361Medicare UPIN
8855327Medicare ID - Type Unspecified