Provider Demographics
NPI:1619141199
Name:ROESIJADI, TANYA (RD, CD)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:ROESIJADI
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3221 NW MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-3322
Mailing Address - Country:US
Mailing Address - Phone:206-527-7204
Mailing Address - Fax:
Practice Address - Street 1:3001 NE 4TH ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98056-4122
Practice Address - Country:US
Practice Address - Phone:206-205-1679
Practice Address - Fax:206-205-1711
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001910133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered